•*K*J*2 












i^T< 












£T<C 



*»*&- 



2^2 

















X0 









tvw* 



mm&m 



vrtbmi 



mwm 



^ITOS»S« 



^M^ffHk 






l| LI BRARY OF CONGRES S. # 






Ml 



J UNITED STATES OF AMERICA. J 



m^r* 






wasmotsa 



mrn^Mm 












If ■'■; r mjh ^ „ Oft* - - It . ; r A*i*AnP\*P* 






so«w 






^'v.-a* 



fpiyps- 


3 1 




s • 


. • * SKMV-" >"*Br 


if 



■;■•:- 
)*a: 






& ^£^# 



WNW 



w-S. 



mmm. 






MECHANICAL THERAPEUTICS 

4 



^ 



% 



PRACTICAL TREATISE 



SURGICAL APPARATUS, APPLIANCES, 



ELEMENTARY OPERATIONS; 

EMBRACING 

BANDAGING, MINOR SURGERY, ORTHOPRAXY, AND THE 
TREATMENT OF FRACTURES AND DISLOCATIONS. 



BY 

PHILIP S. WALES, M.D., Surgeon U.S.N. 



WITH SIX HUNDRED AND FORTY-TWO ILLUSTRATIONS. 







PHILADELPHIA: 

HE^TET 0. LEA 

1867. 
v 




s> 



^>y 



Entered according to the Act of Congress, in the year 1867, by 

HENRY C. LEA, 

in the Office of the Clerk of the District Court of the United States in and for the 
Eastern District of the State of Pennsylvania. 



PHILADELPHIA: 
COLLINS, PRINTER, 705 JaTNE STREET. 



PREFACE. 



In offering to the profession the present volume on mechanical 
therapeutics, the author would state that his design is to place in the 
hands of students and practitioners of medicine a systematized and con- 
densed description of surgical dressings, apparatus, and elementary 
operations, drawn from the writings and teaching of the ablest sur- 
geons in America and Europe. In its preparation care has been taken 
to adapt it also to the necessities of those wishing to enter the public 
service, inasmuch as the rigid and thorough examinations of our 
Military and Naval Medical Boards require more minute and ex- 
tended information upon these subjects than can be obtained from 
the ordinary text-books. 

The author has availed himself of the advantages offered him in 
hospital and private practice, and has submitted to actual trial most of 
the plans of treatment described in the work, noting at the time their 
advantages and disadvantages in the cases in which they have been 
recommended by their authors. All embarrassing generalities have 
been avoided as far as possible in the descriptions, each step in the 
preparation and application of apparatus being minutely detailed. 

In a work of this nature it was indispensable for the easy under- 
standing of the subjects treated that it should be fully illustrated. 
Many engravings introduced throughout the volume have been drawn 
from the well-known works of Yelpeau, Gross, Miller, Erichsen, Fer- 
gusson, Druitt, Skey, Pirrie, and Sargent; while the author would 
also acknowledge special indebtedness to the elaborate treatises of 
Hamilton, Malgaigne, and E. E. Smith, on fractures and dislocations ; 



IV PKEFACE. 

to Goffres' " Precis des Bandages, Pansements et Appareils," Jamain's 
" Manuel de Petite Chirurgie," and to Bigg's Orthopraxy. 

The skilful surgical mechanicians, Mr. Kolbe and Mr. Gemrig, of 
Philadelphia, have been courteous enough to place at his disposal 
models and drawings of the latest surgical apparatus and appliances. 

Philadelphia, Nov. 1867. 



CONTENTS 



PART I . 

OF THE "APPARATUS OF DRESSING." 
CHAPTER I. 







OF THE INSTRUMENTS OF DRESSING. 








PARE 


PAfiE 


The Pocket-Case . . . .33 


Porte-meche ..... 42 


Scalpels 










33 


Directors 






. 42 


Bistouries 










34 


Spatulas . 






42 


Scissors . 










35 


Porte-caustic . 






42 


Razor 










36 


Surgical Needles 






43 


Forceps . 










37 


Trocars . 






43 


Tenaculum 










40 


Catheters 






44 


Lancets . 










40 


Ivory winder for suture threads 


44 


Probes . 










41 











CHAPTER II. 



OF THE FIRST PIECES OF DRESSING. 



Lint 


. 




44 


Sawdust . 








. 51 


Charpie . 






45 


Metallic Plates 








51 


Different Forms of C 


'harpie 




46 


Compresses 








51 


Sponge Tent . 






47 


Simple 








52 


Cotton . 


. 




48 


Splint . 








52 


Oakum . 


. 




49 


Folded 








54 


Tow- 


. 




49 


Knots 








55 


Wool 






49 


Adhesive Plaster 








56 


Raw Silk 






49 


Isinglass Plaster 








58 


Sponge . . 


. 




50 


Collodion 








58 


Moss 






50 


Styptic Colloid 








59 


Cat's-Tail 






50 


The Surgical Tray 








61 


Amadou . 


. 




50 


The Surgical Wallet 






61 


Bran 






51 













CHAPTER III. 

ON THE USE OF SOME TOPICAL REMEDIES. 



Cerates . 


. 62 


Lotions . . 


. 72 


Ointments 


. 64 


Collyria 


. 74 


Plasters . 


. 67 


Gargles 


. 77 


Liniments 


. . . 69 


Collutories .... 


. 73 


Glycerine 


. 70 


Poultices .... 


. 79 



VI 



CONTENTS. 



CHAPTER IV. 

ON THE USE OF WATER IN SURGICAL DISEASES AND INJURIES. 
Sect. I. Water as a Surgical Dressing 



Cold Water-dressings 
Warm Water-dressings . 
Medicated Water-dressings 
Dry Fomentation 
Immersion 
Irrigation 

Cold .... 



Irrigation — 

Warm . . . ... 

Of the Nasal Fossse 
Of the Bladder .... 
Of the Uterus and Vagina . 
The Application of Water by Means 
of India-rubber Sacks 



Sect. II. The Use of Water Generally — Bathing 
General Baths . . . 98 I Local Baths 



93 

93 
94 
94 

95 

98 
98 



CHAPTER V 

INJECTIONS. 



Injection .... 


. 106 


Injection of the Vagina . 


. 110 


Of the Lachrymal Duct 


. 107 


Of the Uterus 


. Ill 


Of the Ear . 


. 107 


Of the Rectum 


. 112 


Of the Urethra . 


. 109 


Of the Cellular Tissue 


. 115 


Of the Bladder . 


. 110 


Of Abnormal Canals . 


. 116 



CHAPTER YI. 

ON THE USE OF GASES AND VAPORS. 

Sect. I. Purification of the Air of Hospitals and Chambers, or Disinfection 117 
Sect. II. The Application of Vapors and Gases to the Skin, or Fumigation . 123 
Sect. III. The Application of Gases, Vapors, and Atomized Liquids to the In- 



terior Cavities 



126 



CHAPTER VII. 

THE "SECOND PIECES" OP DRESSING, OR BANDAGES PROPERLY SO CALLED. 

Sect. I. General Rules for the Preparation and Application of Bandages . 131 

Sect. II. Special Systems of Bandaging 137 

Mayor's 137 1 Rigal's 137 

Sect. III. The Indications Answered by Bandages . - 139 

Sect. IV. Classification of Bandages 158 



CHAPTER VIII. 

SPECIAL OR REGIONAL BANDAGING. 

Sect. I. Bandages for the Head ..... 
Simple Bandages 
Circular Bandages 



Of the Forehead and Eyes 



160 
160 
160 



Simple Bandages — 
Crossed Bandages 
The Monocle 



159 

162 
162 



CONTENTS. 






Vll 




PAGE 




PAGE 


Simple Bandages — 




Compound Bandages — 




The Binocle .... 


162 


Sling Bandages .... 


169 


Single Crossed Bandage for the 




Six-Tailed Bandage of the Head 


170 


Lower Jaw .... 


163 


Four-Tailed Bandage of the Chin 


170 


Double Crossed Bandage for the 




Mask 


171 


Lower Jaw .... 


163 


Sheath Bandages .... 


171 


Crossed Bandage of the Head . 


165 


Sheath Bandage of the Nose . 


171 


Crossed Bandage of the Head 




Sheath Bandage of the Tongue . 


171 


and Neck .... 


165 






Knotted Bandages 


165 


Mayor's Bandages . . 


172 


Knotted Bandage of the Head . 


165 


Circular Cravat .... 


172 


Recurrent Bandages 


166 


Occipito-Frontal Triangle 


172 


Recurrent Bandage of the Head 


166 


Fronto-Occipital Triangle 


172 


Handkerchief Bandages 


167 


Fronto-Oculo-Occipital Triangle . 


172 


Triangular Bandage of the Head 


167 


Bis-Oculo-Occipital Triangle 


172 


Quadrilateral Bandage of the 




Occipito-Mental Triangle 


173 


Head 


167 


Fronto-Cervico- Labial Triangle . 


173 


Invaginated Bandages 


167 


Facial Triangle .... 


173 


Invaginated Bandage of the Lips 


167 


Occipito-Auricular Triangle 


173 


Compound Bandages 


168 


Rigal's Bandages .... 


173 


T Bandages 


168 


Cap . 


. 


. 


173 


T Bandage of the Head and Ears 


168 


Half-Cap . 


. 


. 


173 


Double T Bandage of the Nose . 


168 


Simple Capeline 


, 


. 


174 


T Bandage of the Head . 


168 


Fixed Capeline 


. 


. 


174 


Double T Bandage of the Head . 


168 


Arabic Capeline 


. 


. 


174 


T Bandage of the Mouth . 


169 


Shepherd's Sling 


. 


. 


174 


Crucial Bandages 


169 


Ocular Triangle 


. 


> 


174 


Crucial Bandage of the Head . 


169 






Sect. II. Bandages of the Neck and 


Trun 


K 


175 


Simple Bandages .... 


176 


Simple Bandages — 




Circular Bandages 


176 


The Spica or Figure of 8 of the 




Circular of the Neck 


176 


Shoulder and Opposite Axilla 


179 


Circular of the Chest and Abdo- 




Anterior Figure of 8 of the 




men 


176 


Shoulders .... 


180 


Oblique Bandages 


177 


Posterior Figure of 8 of the 




Oblique Bandages of the Neck 




Shoulders .... 


180 


and Axilla .... 


177 


Crossed Bandage of the Chest . 


180 


Spiral Bandages .... 


177 


Of One Breast 


181 


Spiral Bandages of the Body . 


177 


Of Both Breasts . 


182 


Crossed Bandages 


177 


Of One Oroin 


182 


Posterior Figure of 8 of the Head 




Of Both Groins . 


183 


and Axillas .... 


177 






Anterior Figure of 8 of the Head 




Compound Bandages 


183 


and Axillas .... 


178 


T Bandages .... 


183 


Figure of 8 of the Head and One 




Double T of the Chest and Ab- 




Axilla ..... 


178 


domen ..... 


183 


Figure of 8 of the Neck and 




Anterior Double T of the Head 




Axilla 


178 


and Chest 


. 


. 


184 



Vlll 



CONTENTS, 



Compound Bandages — 

Posterior Double T of the Head 

and Chest . . . .184 
Double T of the Pelvis . . 184 
T Bandage of the Groin . .184 

The Crossed Bandage of the Trunk 185 

Sling Bandages .... 185 
Of the Shoulder . . .185 
Of the Breast . . . .185 
Of the Hip ... 186 

Suspensory Bandages . . . 186 
Of the Breast . . . .186 
Of the Testicle . . .187 

Sheath Bandages . . .187 

Of the Penis . . . .187 

Mayor's Bandages for the Neck and 

Trunk 187 

Cravat of the Neck . . .187 
Occipito-Thoracic Triangle . . 187 
Fronto-Thoracic Triangle . . 188 
Parieto-Axillary Triangle . .188 
Thoracico-Scapular Triangle . 188 

Simple Bis-Axillary Cravat . . 188 
Compound Bis-Axillary Cravat . 188 



Mayor's Bandages — 

Simple Dorso-Bis-Axillary Cravat 189 
Compound Dorso-Bis-Axillary Cra- 
vat 189 

Cravat, Triangle, and Squares . 189 
Triangular Cap of the Breast . 189 
Cervico-Thoracic Cravat . . 189 
Cervico-Dorso-Sternal Cravat . 189 
Sacro-Pubic Triangle . . . 189 
Intercrural Cravat . . . 190 
Cruro-Pelvic Triangle . . .190 
Cruro-Pelvic Cravat . . .190 
Sacro-Bi-Crural Cravats . . 190 
Sacro-Lumbar Triangle . . 190 

Coxo-Pelvic Triangle . . .190 

Rigal's Bandages for the Neck and 

Trunk 191 

Cervico- Axillary Cravat . .191 
Lateral Thoracic Bandage . .191 
Sternal Triangle . . . .191 
Dorsal Triangle . . . .192 
Thoracico-Abdominal Bandage . 192 
Girdle 192 



Sect. III. Bandages for the Upper Extremities 



Simple Bandages .... 194 

Circular Bandages . . .194 
Of a Finger . . . .194 
Of the Forearm . . .194 
Of the Arm . . . .194 

Spiral Bandages .... 195 
Of a Finger . . . .195 
Of all the Fingers (Gauntlet) . 195 
Of the Hand and Fingers . .196 
Of the Forearm . . .196 
Of the Arm . . . .196 
Of the Whole Arm . . .197 

Figure of 8 Bandages . . . 197 
Of the Thumb and Wrist . 198 
Posterior, of the Hand and Wrist 198 
Anterior, of the Hand and Wrist 198 
Of the Elbow . . . .198 
Extensor, of the Hand and Fore- 
arm 199 

Flexor, of the Hand and Forearm 199 

Recurrent Bandages . . . 199 
Of a Stump of the Arm and 

Forearm .... 199 
After Disarticulation at the 
Shoulder . . . .199 



.... 193 

Simple Bandages — 

Handkerchief Bandages . . 200 
Large Quadrilateral Scarf of the 

Arm and Chest . . .200 
Oblique Quadrilateral Scarf of 

the Arm and Chest . . 200 
Scarf of the Arm and Neck . 201 
Scarf of the Hand and Forearm 201 

Compound Bandages . . . 201 

T Bandages 201 

Simple T Bandage of the Hand . 201 
Double T Bandage of the Hand . 201 
Perforated T Bandage of the 
Hand 202 

Sling Bandages . . . .202 
Of the Hand . . . .202 
Anterior, of the Elbow . . 202 
Posterior, of the Elbow . . 202 

Sheath Bandages . . . .202 
Of the Fingers . . . .202 

Laced and Buckle Bandages . 202 

Laced Bandage of the Arm . 202 
Laced Bandage of the Body 
(Strait-Jacket) . . .202 



CONTENTS. 



IX 



Mayor's Bandages of the Upper Ex- 



Mayor's Bandages — 



TREMITIES . 


. 


. 203! 


Cervico-Brachial Triangle 


205 


Cravats, Triangles, and Squares . 203 | 


Triangular Cap of the Shoulder . 


205 


Carpo-Digito Dorsal Triangle 


. 203 


Triangular Cap of Stumps . 


205 


Interdigital Triangle . 


. 204 






Palmo-Digito-Brachial Triangle . 204 


Rigal's Bandages of the Upper Ex- 




Carpo-Olecranon Cravat 


. 204 


tremities ..... 


205 


Carpo-Cervical Triangle 


. 205 


Deltoid Bandage .... 


205 


Sect. IV. Bandages for the Lower Extremities ....... 


206 


Simple Bandages 


. 207 


Compound Bandages — 




Circular Bandages 


. 207 


Sheath Bandages 


214 


Of a Toe . 


. 207 


Of a Toe 


214 


Of the Leg 


. 207 


Laced Bandages .... 


214 


Spiral Bandages . 


. 207 


Of the Lower Extremity . 


214 


Of a Toe . 


. 207 






Of the Leg 


. 208 


Mayor's Bandages for the Lower 




Of the Thigh . 


. 208 


Extremities .... 


215 


Of the Lower Extremity 


. 208 


Cravats, Triangles, and Squares of 




Figure of 8 Bandages . 


. 209 


the Toes, Foot, Leg, and Thigh . 


215 


Of a Toe . 


. 209 


Imbricated Squares and Cravats . 


215 


Of the Foot and Leg 


. 210 


Tibial Triangle .... 


215 


Posterior, of the Knee 


. 210 


Popliteal Cravat .... 


215 


Anterior, of the Knee 


. 210 


Tarso-Patellar Cravat . 


215 


Of both Knees . 


. 210 


Compound Metatarso-Patellar Cra- 




Recurrent Bandages 




. 211 


vat 


215 


Of the Leg 




. 211 


Tarso-Pelvic and Tarso-Crural Cra- 




Of the Thigh . 




. 211 


vats 


216 


Of the Hip 




. 211 


Triangular Cap for Stumps . 


216 


Invaginated Bandages 




. 211 


Triangular Cap for the Heel . 


216 


For Longitudinal "Wounds 


. 211 


Metatarso-Malleolar Cravat . 


216 


For Transverse Wounds 


. 212 


Malleolar-Phalangeal Triangle 


216 






Tibio-Cervical Cravat . 


217 


Compound Bandages 


. 213 


Uniting Cord for Longitudinal 




T Bandages . 




. 213 


Wounds 


217 


Single, of the Foot 




. 213 






Double, of the Foot 




. 213 


Rigal's Bandages for the Lower Ex- 




Sling Bandages . 




. 214 


tremities 


217 


Of the Instep . 




. 214 


Triangle of the Trochanter Major 


217 


Of the Heel 




. 214 


Bandage for the Leg- 


217 


Of the Knee . 




. 214 


Bandage for the Foot . 


217 



CONTENTS. 

PART II. 

MECHANICAL BANDAGES AND APPAKATUS. 



CHAPTER I. 

APPARATUS FOR REMEDYING LOSS OP PARTS. 



Sect. I. Loss of Parts of the Head and Neck 



219 
219 

220 

222 



Deficiency of the Cheeks and Lips 
Of the Palate 
Of the Chin 



Deficiency of the Cranial Walls 
Of the Integuments 
Of the Nose 
Of the Eye .... 

Sect. II. Apparatus for Remedying Deficiencies of the Trunk 
Deficiency of the Thoracic Walls . 227 I Deficiency of the Spinal Canal 

Sect. III. Apparatus for Remedying Deficiencies of the Upper Extremities 
Deficiency of the Arm 

Sect. IV. Apparatus for Remedying Deficiencies of the Lower Extremities 
Deficiency of the Leg .......... 



PAGE 

219 
223 

223 
226 

227 
228 

228 
228 

237 
237 



CHAPTER IT. 

APPARATUS FOR REMEDYING LOSS OF FUNCTION OF PARTS OF THE BODY. 

Sect. I. Apparatus for Remedying Loss of Function of the Muscles of the 

Head and Neck 252 

Loss of Function of the Cervical Muscles 252 

Sect. II. Apparatus for Remedying Loss of Function of Muscles of the Trunk 253 



Loss of Function of the Erector Mus- 
cles of the Spine . . . 253 
Of the Abdominal Muscles — Her- 
nia 254 



Loss of Function — 

Of the Sphincter Ani . 
Of the Uterine Ligaments — Pro- 
lapsus Uteri .... 



Sect. III. Apparatus for Remedying Loss of Function of Parts of the Upper 
Extremities ............ 



Loss of Function of the Muscles of 

the Fingers .... 274 
Of the Interossei Muscles . . 276 
Of the Extensor Communis Digi- 
torum 277 



Loss of Function — 

Of the Extensors of the Hand 

Of the Biceps 

Of the Scapular Muscles 



Sect. IV. Apparatus for Remedying the Loss of Function of Parts of the 
Lower Extremities ........... 



Loss of Function of the Tibialis An- 

ticus 281 

Of the Peronei Muscle . . .281 
Of the Extensor Muscles of the Leg 282 



Loss of Function — 

Of the Ligament of the Knee-Joint 
— Knock-Knee .... 
Of the Ligament of the Hip 



267 
268 

274 

278 
279 
279 

280 



284 
289 



CONTENTS. 



XI 



CHAPTER III. 



APPARATUS FOR REMEDYING LOSS OF SYMMETRY OF PARTS. 
Sect. I. Apparatus for Remedying Loss of Symmetry of the Head and Neck 



Deformity of the Nose . . .289 

Immobility of the Lower Jaw . . 290 

Projection of the Chin . . .291 

Distortion of the Lips from Burns . 291 



Deformity of the Chin and Neck from 

Burns 

Posterior Curvature of the Neck 
Angular Cervical Curvature . 
Torticollis 



Sect. II. Apparatus for Remedying Loss of Symmetry of the Trunk 
Lateral Curvature of the Spine . 297 Angular Curvature of the Spine 
Posterior Curvature of the Spine . 309 Loss of Symmetry of the Pelvis 

Sect. III. Apparatus for Remedying Loss of Symmetry of the Upper Extremi- 
ties 

Deformity of the Fingers . . 315 I Deformity of the Elbow . 

Deformity of the Wrist . . 317 | 

Sect. IV. Apparatus for Remedying Loss of Symmetry of the Lower Extremi- 
ties 

Deformities of the Toes . 
Bunions ..... 
Deformity of the Foot and Ankle 



320 I Bowed or Bandied Legs . 

321 j Contraction of the Knee-Joint . 

322 Contraction of the Hip . 



PAGE 

289 

291 
292 

293 
294 

297 
310 
314 

315 
318 



320 
331 
333 
336 



PART III. 

FRACTURES: THEIR REDUCTION, DRESSINGS, AND APPARATUS. 

CHAPTER I. 

GENERAL CONSIDERATION OF FRACTURES. 



Classification . 


. 346 


Mode of Repair 


. 350 


Frequency 


. 347 


Ununited Fracture . 


. 352 


Causes 


. 347 


Treatment of Ununited Fracture 


. 352 


Symptoms 


. 348 


Compound Fracture 


. 354 


Diagnosis 


. 350 


Complicated Fracture 


. 355 


Prognosis 


. 350 


General Treatment of Fractures 


. 355 



CHAPTER II. 

FRACTURES OF PARTICULAR BONES. 

Sect. I. Fractures of the Bones of the Skull axd Face . 



Fracture of the Skull 



373 Fracture of the Malar Bone 



Of the Nasal Bones and Cartilages 374 
Of the Superior Maxillary Bone . 37G 



Of the Zygoma . 

Of the Inferior Maxillary 



373 

378 
378 
379 



Xll 



CONTENTS 









PAGE 


Sect. II. Fractures of the Bones of the Trunk .... 


. 386 


Fracture of the Hyoid Bone . 


. 386 


Fracture of the Sternum 


. 390 


Of the Laryngeal Cartilages 


. 387 


Of the Ribs 


. 391 


Of the Vertebrae . 


. 388 


Of the Costal Cartilages 


. 393 


Sect. III. Fractures of the Bones of the Upper Extremities . 


. 393 


Fracture of the Scapula . 


. 393 


Fracture — 




Of the Clavicle . 


. 397 


Of the Ulna 


. 431 


Of the Humerus . 


. 409 


Of the Carpus 


. 434 


Of the Radius and Ulna 


. 423 


Of the Metacarpus 


. 434 


Of the Radius 


. 425 


Of the Phalanges 


. 435 


Sect. IV. Fractures of the Bon 


es of the Lower Extremities . 


. 435 


Fracture of the Pelvic Bones . 


. 435 


Fracture of the Fibula . 


. 491 


Of the Femur 


. 437 


Of the Tarsal Bones 


. 493 


Of the Patella . 


. 471 


Of the Metatarsal Bones 


. 494 


Of the Tibia and Fibula 


. 480 


Of the Phalanges 


. 494 


Of the Tibia 


. 490 


Rupture of the Tendo-Achillis 


. 495 



PART IV. 

DISLOCATIONS: THEIR REDUCTION, DRESSINGS, AND 
APPARATUS. 

CHAPTER I. 

SPRAINS OR STRAINS .... 





CHAPTER II. 




DISLOCATIONS IN GENERAL 


Nomenclature . 


. 500 


Symptoms 


Frequency 


. 501 


Diagnosis 


Causes 


. 502 


Prognosis 


Pathological Anatomy 


. 503 


Treatment 



504 
506 
506 
507 



CHAPTER III. 

PARTICULAR DISLOCATIONS. 

Sect. I. Dislocations of the Head and Trunk 511 

Dislocation of the Inferior Maxilla . 511 | Dislocation of the Sternum . .516 
Of the Vertebra? .... 514 | Of the Ribs and Costal Cartilages 516 

Sect. II. Dislocations of the Up* 
Dislocation of the Clavicle 

Of the Humerus . 

Of the Radius and Ulna 

Of the Radius 



XTRI 


:mities 


. 517 


517 


Dislocation of the Ulna . 


. 538 


523 


Of the Carpus 


. 539 


532 


Of the Metacarpus 


. 541 


536 


Of the Phalanges 


. 542 



CONTEXTS. 



XI 11 



Dislocation of the Pelvic Bones 
Of the Femur 
Of the Patella . 
Of the Tibia 
Of the Semilunar Cartilages 



wee Extremities 




. 547 


. 547 


Dislocation of the Fib 


ila 


. 560 


. 54S 


Of the Foot 


. 


. 561 


. 556 


Of the Tarsus 


. 


. 565 


. 557 


Of the Metatarsus 


. 


. 568 


. 560 


Of the Phalanges 


• 


. 509 



PART V. 

THE MINOR OPERATIONS OF SURGERY. 



Actual Cauterization 
Galvanic Cauterization 



CHAPTER I. 

RUBEFACTION , 



CHAPTER II. 

VESICATION 



CHAPTER III. 

CAUTERIZATION 



577 

579 



Potential Cauterization 



CHAPTER IY, 

MOXAS . 

CHAPTER Y. 

ISSUES . 



70 



573 



581 



585 



586 



CHAPTER YI. 

SETONS . 



589 



CHAPTER VII. 

ACUPUNCTURE AND ELECTRO-PUNCTURE 



591 



CHAPTER VIII. 

PUNCTURING 



592 



CHAPTER IX 

VACCINATION . 



595 



CHAPTER X. 

INCISIONS 



596 



XIV 



CONTENTS. 



CHAPTER XI. 

BLOODLETTING. 



Sect. I. General Bleeding 
Venesection . 



. 600 I Arteriotomy 

Sect. II. Local Bleeding 

Cupping 608 I Leeching 



600 
606 

608 
610 



CHAPTER XII. 

EXTRACTION OF TEETH 



614 



CHAPTER XIII. 

CATHETERISM. 



Catheterism of the Nasal Duct . 619 

Of the Eustachian Tuhe . . 620 

Plugging the Posterior Nares . . 621 

Catheterism of the Oesophagus . 623 

Of the Larynx and Trachea . 624 



Catheterism of the Large Intestines 
Of the Uterus 
Of the Urethra . 

Male Urethra . 

Female Urethra 



CHAPTER XIY. 

REMOVAL OF FOREIGN BODIES. 



625 
625 
625 
626 
629 



Foreign Bodies in the Skin 


. 630 


Foreign Bodies — 




In the Eye .... 


. 632 


In the Larynx and Trachea . 


. 637 


In the Ear .... 


. 632 


In the Urethra and Bladder 


. 639 


In the Nose 


. 635 


In the Vagina * 


. 641 


In the Pharynx and Oesophagi 


is . 635 


In the Rectum 


. 641 



CHAPTER XV. 

ON THE MODES OF ARRESTING HEMORRHAGE 



642 



Incised Wounds 
Contused Wounds 



CHAPTER XYI. 

ON THE DRESSINGS OF WOUNDS. 

655 I Punctured Wounds 
. 662 Gunshot Wounds 



662 
663 



Local Anaesthesia 



CHAPTER XVII. 

ANESTHESIA. 

. Q6Q ! General Anaesthesia 



m 



LIST OF ILLUSTRATIONS 



1. Single-bladed scalpel . . 34 

2. Double-bladed scalpel . . 34 

3. 1 

4. J 

5. [ Different forms of the scalpel 35 

6. j 

7. J 

8. Straight bistoury ... 35 

9. Curved sharp-pointed bistoury. 36 

10. Curved blunt-pointed bistoury 36 

11. Straight scissors ... 36 

12. Scissors curved on the edge . 37 

13. Scissors curved on the flat . 37 

14. Razor for the pocket-case . . 37 

15. Dressing-forceps , . . 38 

16. Artery forceps with slide . 38 

17. Forceps for holding pins in ma- 

king twisted suture . . 39 

18. Artery forceps with arched 

points 39 

19. Artery forceps closing by their 

own spring .... 39 

20. Liston's forceps ... 40 

21. Tooth-pointed forceps . . 40 

22. Tenaculum .... 40 

23. Lancet 40 

24. Syme's abscess lancet . . 41 

25. Gum lancet .... 41 

26. Simple probe .... 41 

27. Gunshot probe ... 41 

28. Porte-meche .... 42 

29. Directors .... 42 

30. Spatula 42 

31. Porte-caustic .... 42 

32. Surgical needles ... 43 

33. Exploring needle ... 43 

34. Exploring trocar ... 43 

35. Catheters .... 44 

36. Ivory winder for suture thread 44 

37. The many-tailed bandage . 52 



FIG. 

38. 

39. 
40. 
41. 
42. 
43. 
44. 
45. 
46. 
47. 
48. 
49. 
50. 
51. 
52. 
53. 
54. 
55. 
56. 
57. 
58. 



59. 
60. 

61. 

62. 
63. 

64. 
65. 
66. 
67. 
68. 
69. 

70. 



Application of the bandage of 

Scultetus .... 53 

The Maltese cross ... 54 

Folded compresses ... 54 



Different forms of knots 55, 56 



Application of the many-tailed 
bandage for retaining cata- 
plasms 

Apparatus for cold water-dress 
ings .... 

Velpeau's apparatus for irriga 
tion .... 

Double-tubed catheter . 

Maisonneuve's irrigator . 

India-rubber cap for applying 
cold water to the head . 

Thomson's bathing apparatus 

Portable shower-bath 

Vessel for hip-bath . 

Anel's syringe 

Toynbee's syringe and nozzle 

Toynbee's ear-spout fitted on 
the head 

The catheter syringe 



81 



91 
94 
95 

96 
101 

102 
106 

107 
108 

108 
109 



XVI 



LIST OF ILLUSTRATIONS. 



FIG. 

71. 

72. 
73. 
74. 
75. 
76. 
77. 
78. 
79. 

80. 

81. 

82. 

83. 
84. 
85. 
86. 
87. 
88. 
89. 

90. 

91. 

92. 

93. 
94. 

95. 
96. 

97. 

98. 



100. 
101. 
102. 
103 
104, 
105 



Metallic clyster-pump 
Hypodermic syringe 
Brindej one's ventilator 

I Inhalers 



Atomizer of Sales-Girons 

Steam atomizer 

Shield to protect the face 

Apparatus for applying carbo- 
nic acid to the uterus . 

Mode of making the single- 
headed roller 

Bandage-roller 

Mode of applying the roller 
bandage .... 

The square Mayor's bandage . 

The oblong " " 

The triangle " " 

The cravat " " 

The cord " 

Mode of strapping the breast . 

Velpeau's bandage for support- 
ing a pendulous abdomen . 

Dewar's apparatus for support- 
ing the suture in hare-lip . 

Carte's compressor for femoral 
and popliteal aneurism 

Carte's compressor for aneurism 
of the upper extremities 

Hoey's clamp .... 

Charriere's compressor . 

Baynton's plan of treating ulcers 

Bandage scissors 

Fricke's plan of treating or- 
chitis 

Urethral dilators 
Buchanan's compound circular 
catheter .... 
Sheppard's dilator . 

1 

I Wakely's dilators for stric- 
ture .... 



'•J 



106 
107 
108 
109 
110 
111 



Fergusson's mode of ligating 
nsevus ..... 
Erichsen's method of ligating 
vascular tumors 
Double canula 

Ecraseurs .... 
. Bandage for the eye 
Monocle 



:} 



PAGE 


FIG. 




PAGE 


112 


112. 


Recurrent bandage of the head 


166 


116 


113. 


Invaginated bandage for verti- 




123 




cal wounds of the lips . 


167 


127 


114. 


Double T bandage of the nose . 


168 


115. 


Six-tailed bandage of the head 


170 


128 


116. 


Four-tailed bandage of the 




129 




head 


170 


129 


117. 


Four-tailed bandage of the chin 


171 




118. 


Sheath bandage of the tongue 


171 


130 


119. 


Spica of the shoulder 


179 




120. 


Anterior figure of 8 of the 




134 




shoulders .... 


180 


134 


121. 


T bandage of the groin . 


185 




122. 


] Suspensory bandage of the 
J scrotum .... 




135 


123. 


186 


138 


124. 


Elastic suspensory bandage of 




138 




scrotum .... 


187 


138 


125. 


Simple bis-axillary cravat 


188 


138 


126. 


Cruro-pelvic triangle 


190 


139 


127. 


Sacro-lumbar triangle 


191 


141 


128. 


Circular bandage of a finger . 


193 




129. 


Spiral of all the fingers (Gaunt- 




142 




let) 


195 




130. 


Demi-gauntlet 


196 


143 


131. 


Spiral bandage of the whole 








arm 


197 


146 


132. 


Carpo-olecranon cravat . 


204 




133. 


Spiral bandage of the lower 




146 




extremity .... 


209 


146 


134. 


Posterior figure of 8 of the knee 


210 


146 


135. 


} Invaginated bandage for ver- 
) tical wounds 




148 


136. 


212 


148 


137. 


Invaginated bandage for trans- 








. verse wounds 


213 


150 


138. 


Sling of the knee . 


214 


152 


139. 


Elastic bandage of lower extre- 








mity ... 


214 


152 


140. 


] 




153 


141. 
142. 


I Artificial nose 


221 




143. 


Artificial eye .... 


222 


153 


144. 


Artificial palate . . 


224 




145. 
146. 


1 Hullihen's artificial palate . 


225 


155 


147. 


Van Petersen's artificial arm . 


229 




148. 


L Charriere's artificial arm 


230 


155 


149. 




156 


150. 


Common artificial arm . 


234 


157 


151. 


Artificial arm with driving hook 


235 


161 


152. 


Diagram showing centre of 




161 




gravity .... 


238 



LIST OF ILLUSTRATIONS. 



XV11 



FIG. 

153. 

154. 

155. 
156. 

157. 

158. 
159. 



160. 
161. 
162. 
163. 
164. 
165. 
166. 
167. 
168. 
169. 
170. 
171. 
172. 
173. 
174. 
175. 

176. 
177. 

178. 
179. 
180. 
181. 
182, 
183. 

184. 

185. 
186. 
187. 

188. 

189. 
190. 



Shoe after amputation at the 

ankle 239 

Apparatus for amputation 
through the foot . . .240 

Common socket leg . . 241 

Artificial leg for amputation be- 
low the knee . . . 241 

Apparatus for extending a con- 
tracted stump . . . 242 

Wooden pin . . . . 242 

Diagram showing the mode of 
arranging spiral' springs in 
the ankle . . . .244 

Bly's artificial leg . . . 247 

| Kolbe's artificial leg . . 248 

Apparatus for spinal debility . 254 

Single inguinal truss . . 256 

Salmon and Ody's single truss. 256 

Salmon and Ody's double truss 256 

Todd's truss .... 257 

Bigg's truss .... 257 

Hood's truss .... 258 

Dupre's truss .... 259 

Femoral truss .... 360 

Umbilical truss . . . 261 

I Apparatus for prolapsus ani. 268 

Mode of introducing the India- 
rubber pessary . . . 270 

| Different forms of India-rub- 
ber pessaries . . . 270 

Hodge's closed lever pessary . 270 
Gariel's pessary . . . 272 
Uterine supporter, front view . 273 
Uterine supporter, back view . 273 
Uterine supporter with mova- 
ble pad .... 273 
Velpeau's apparatus for writer's 
cramp 275 

[ Apparatus for writer's cramp 275 

Apparatus for paralysis of the 

interossei muscles. . . 276 

Apparatus for paralysis of the 

extensor communis . . 277 

Apparatus for " drop wrist" . 278 

Apparatus for paralysis of the 

biceps 279 



PIG. PAGB 

191. Apparatus for paralysis of the 

tibialis anticus . . . 281 

192. Supporting frame for paralysis 

of the lower extremities . 282 

193. l Apparatus for paralysis of 

194. J the lower extremity . 283 

195. I Apparatus for paralysis of 

196. j both extremities . . 284 

197. Appearance of knock-knee . 285 

198. Knock-knee with outward cur- 

vature of the opposite knee . 286 

199. -j 2g7 

200. I Apparatus for knock-knee . 2 C8 

201. J 

202. Scultetus' lever for separating 

the jaws . . . .290 

203. Lever for opening the jaws . 290 

204. Bigg's apparatus for separating 

the jaws . . . .29,0 

205. Apparatus to prevent deformity 

of the lips . . . .291 

206. Apparatus for preventing de- 

formity after burns . . 292 

207. Bishop's apparatus for caries of 

the cervical vertebrae . . 294 

208 . Gutta-percha shield for caries of 

the vertebrae . . . 294 

209. Bigg's apparatus for caries of 

the cervical vertebrae . . 294 

210. Jorg's apparatus for torticollis. 295 

211. Bonnet's apparatus for torti- 

collis 295 

212. Bigg's apparatus for torticollis. 296 

213. Apparatus for torticollis . . 296 

214. Same applied . . . .296 

215. Another form of apparatus for 

torticollis . . . .296 

216. "j External appearances of late- 

217. j ral curvature . . . 298 

218. Appearance of the bones in late- 

ral curvature, front view . 299 

219. Appearance of the bones in late- 

ral curvature, back view . 299 

220. Recumbent couch for lateral 

curvature .... 301 

221. Bigg's couch for lateral curva- 

ture 303 

222. Maisonabe's couch for lateral 

curvature .... 303 

223. Apparatus for lateral curvature 304 



XV111 



LIST OF ILLUSTRATION'S. 



FIG. PARE 

224. Tavernier's apparatus for late- 

ral curvature . . . 304 

225. Tamplin's apparatus for lateral 

curvature .... 305 

226. Lonsdale's apparatus for lateral 

curvature . . . .306 

227. Bigg's apparatus for lateral 

curvature . . . .306 

228. Brodie's apparatus for lateral 

curvature .... 307 

229. Duchenne's apparatus for late- 

ral curvature . . . 307 

230. Kolbe's modification of Du- 

chenne's apparatus . . 308 

231. Apparatus for lateral curvature 308 

232. Apparatus for single curvature 

of the spine . . . 309 

233. Appearance of posterior curva- 

ture of the spine . . . 309 

234. Tamplin's apparatus for poste- 

rior curvature . . . 310 

235. Appearance of angular curva- 

ture 311 

236. Tamplin's apparatus for angu- 

lar curvature . . .313 

237. ") Apparatus for angular curva- 

238. J ture . . . .314 

239. Apparatus for obliquity of the 

pelvis ..... 314 

240. 1 Congenital deformities of the 

241. j fingers . . . .315 

242. | Deformities of the fingers from 

243. J contraction of palmar fascia 316 

244. Deformity of the fingers from 

wound of forearm . .316 

245. Deformity of the fingers from 

contraction of the skin . 316 

246. Contraction of the wrist . .317 

247. "I Apparatus for deformities of 

248. } the wrist . . . .318 

249. Contraction of the elbow . . 318 

250. Stromeyer's apparatus for an- 

chylosis of the elbow . . 319 

251. Bonnet's apparatus for anchy- 

losis of the elbow . . 319 

252. Contraction of the toe . . 320 

253. " Hammer toe" . . .320 

254. Appearance of bunion . . 321 

255. Apparatus for bunion . . 321 

256. Appearance of talipes varus . 322 

257. Kolbe's club foot apparatus . 326 



FIG. 

258. 
259. 
260. 

261. 
262. 
263. 
264. 
265. 
266. 
267. 
268. 
269. 
270. 
271. 

272. 

273. 

274. 
275. 



276. 
277. 
278. 
279. 
280. 
281. 
282. 
283. 
284. 
285. 
286. 
287. 
288. 
289. 

290. 

291. 

292. 
293. 
294. 

295. 

296. 



j- Little's club-foot apparatus . 327 

Modification of Little's appara- 
tus 328 

| Appearance of talipes equi- 

J nus 328 

Stromeyer's foot-board . . 329 

Liston's apparatus . . . 329 

Appearance of talipes calcaneus 331 

Apparatus for talipes calcaneus 331 
Shoe for club-foot . . .331 
Bowed legs - . . . .332 

I Apparatus for bowed legs . 332 

Apparatus for anterior curva- 
ture of the leg . . . 333 
Apparatus for contraction of the 

knee ..... 333 
Bonnet's apparatus for con- 
tracted knee . . . 334 
Tamplin's apparatus for con- 
tracted knee . . . 335 
Appearance of contracted knee 
with displacement of the tibia 
backwards .... 335 
1 Bigg's apparatus for con- 
j tracted knee . . .336 
1 Dr. Davis's splints for coxal- 

} gia 339 

Dr. Davis's splints for coxalgia 340 

Davis's splint applied . . 340 

Barwell's splint for coxalgia . 341 

Agnew's splint for coxalgia . 342 

Same applied .... 343 

I Apparatus for coxalgia . 343 

Wire splint . . . .344 

Mode of applying wire splint . 343 
Smith's apparatus for ununited 

fracture of the thigh . . 353 
Smith's apparatus for ununited 

fracture of the leg . . 353 
Air-cushions for splints . .358 

The same applied . . . 358 

Seutin's scissors . . . 359 
Diagram for making pasteboard 

splints for the thigh . .359 
Diagram for making pasteboard 

splints for the leg . .360 
Diagram for making pasteboard 

splints for the arm . . 360 



LIST OF ILLUSTRATIONS. 



XIX 



FIG. 

297. Diagram for making pasteboard 

splints for the forearm . 

298. Pasteboard splints for the thigh 

299. Pasteboard splints for the fore- 

arm 

300. Application of pasteboard 

splints to the leg . 

301. Welch's splint for the forearm . 

302. Seutin's apparatus for fracture 

of the thigh 

303. Immovable apparatus for leg . 

304. Specimen showing three forms 

of fracture of the lower jaw 

305. Barton's bandage for fractured 

lower jaw . 

306. Gibson's bandage for fracture of 

lower jaw .... 

307. Hamilton's apparatus for frac- 

tured jaw . 

308. I The author's apparatus for 

309. J fractured jaw . 

310. 1 Bean's apparatus for frac- 

311. j turedjaw. 

312. Fracture of the acromion process 

313. Fracture of the coracoid process 

314. Fracture of the neck of the 

scapula .... 

315. Apparatus for fracture of the 

neck of the scapula 

316. Fracture of the body of the 

scapula .... 

317. Oblique fracture near the mid- 

dle of the clavicle 

318. Figure of 8 bandage for frac- 

tured clavicle . . 

319. Brasdor's apparatus for frac- 

tured clavicle 

320. Kecherly's apparatus for frac- 

tured clavicle 

321. Velpeau's apparatus for frac- 

tured clavicle 

322. Lonsdale's apparatus for frac- 

tured clavicle 

323. Fox's apparatus for fractured 

clavicle . . •' . 

324. Hamilton's apparatus for frac- 

tured clavicle 

325. ■> Levis's apparatus for frac- 

326. J tured clavicle . 

327. Fracture of the anatomical neck 

of the humerus . 



PAGE 


FIG. 




328 


361 




361 


329 


361 


330 




331 


362 




363 


332 


366 


333. 


367 


334. 


379 


335 


382 


336 




337. 


382 


338. 




339. 


383 


340. 




341. 


385 


342. 




343. 


386 




393 


344. 


394 






345. 


395 




• 


346. 


395 





1347. 



397 
399 
399 
400 
401 
405 
406 
406 
407 
409 2 



349. 

350. 

351. 

352. 

353. 

354. 

355. 

356. 
357. 



Fracture of the surgical neck of 
the humerus . . . 411 

Apparatus for fracture of surgi- 
cal neck of humerus . . 413 

Welch's shoulder-splint . .413 

Lonsdale's apparatus for frac- 
ture of humerus . . .415 

Fracture at the base of the con- 
dyles 416 

Physick's elbow splints . . 416 

Sir A. Cooper's splint for frac- 
ture of the humerus . .417 

Fergusson's mode of treating 
fracture above the condyles . 417 

Hamilton's elbow splint . . 418 

Bond's elbow splint . . . 418 

Welch's elbow splint . . 419 

Kirkbride's elbow splint . .419 

Rose's splint . . . .420 

Day's splint .... 420 

Mayor's splint .... 420 

Fracture at the base of and be- 
tween the condyles . . 421 

Fracture of the external con- 
dyle 421 

Fracture of the internal con- 
dyle 422 

Fracture in the lower third of 
humerus .... 423 

Mayor's apparatus for fracture 
of the forearm . . . 425 

Fracture of the shaft of the 
radius ..... 426 

Fracture of the radius near its 
lower end .... 426 

Dupuytren's apparatus for frac- 
ture of the radius . . 427 

Nelaton's splint for fracture of 
the radius .... 427 

Bond's splint for fractured ra- 
dius . - . . . .428 

Bond's splint with strips at- 
tached . ". . . . .428 

Hay's splint for fracture of the 
radius 429 

Smith's modification of Bond's 
splint, back view . . 4*29 

Same, front view . . . 429 

Hamilton's splint for fracture 
of the radius . . .430 

Hamilton's splint applied . 430 



LIST OF ILLUSTRATIONS. 



FIG. 

359. 
360. 
361. 
362. 
363. 

364. 

365. 

366. 

367. 
368. 
369. 

370. 

371. 
372. 
373. 
374. 
375. 
376. 
377. 
378. 

379. 
380. 

381. 

382. 
383. 
384. 
385. 
386. 
387. 

388. 
389. 
390. 

391. 
392. 
393. 



Fracture of the olecranon pro- 
cess 

Sir A. Cooper's apparatus for 
fracture of olecranon . 

Mayor's apparatus for fractured 
olecranon .... 

Fracture of the coronoid pro- 
cess 

Apparatus for fracture of the 
coronoid process . 

Fracture of the shaft of the ulna 

Splint for fracture of the hones 
of the fingers 

Fracture of the pubis and is- 
chium 

Intra-capsular fracture 

External characteristics of frac- 
ture of neck of femur . 

Gibson's modification of Hage- 
dorn's apparatus . 

Gross's fracture apparatus 

Liston's splint 

") Walton's modification of 

J Liston's splint . 

Daniels' fracture-bed 

Same, with patient upon it 

Extra-capsular fracture . 

Miller's splint for fracture of 
neck of femur 

Same, applied .... 

Sir A. Cooper's apparatus for 
fracture of the trochanter 
major ..... 

Fracture at the base of the con- 
dyles ..... 

Jenk's fracture-bed . 

Hewson's fracture-bed . 

Part of same .... 

Double-inclined plane 

Same, applied .... 

Amesbury's double-inclined 
plane 

Same, applied .... 

Nott's double-inclined plane . 

N. R. Smith's double-inclined 
plane 

N. R. Smith's anterior splint . 

Same, applied .... 

Palmer's modification of the 
anterior splint . . / 



431 
432 
432 

433 

434 
434 

435 

437 

438 

438 

440 
441 
442 

442 
443 
444 
445 

446 

446 



447 

448 
449 
450 
451 
454 
454 

455 
455 
456 

457 
457 
458 



FIG. 

394. 

395. 

396. 

397. 

398. 
399. 

400. 
401. 

402. 

403. 
404. 
405. 

406. 
407. 

408. 

409. 

410. 

411. 

412. 

413. 

414. 

415. 
416. 

417. 
418. 

419. 

420. 

421. 

422. 



Physick's splint for fractured 
thigh 

Boyer's apparatus for fractured 
thigh 

Chapin's apparatus for frac- 
tured thigh .... 

Horner's apparatus for frac- 
tured thigh .... 

Hartshorne's apparatus . 

Burges' apparatus for fractured 
thigh 

Same, applied .... 

Sanborn's apparatus for frac- 
tured thigh .... 

Neill's apparatus for fractured 
thigh 

] Hodge's mode of making 
j counter-extension 

Gilbert's mode of counter- ex- 
tension .... 

Gilbert's apparatus applied 

Dugas' apparatus for fractured 
thigh 

Dugas' mode of attaching the 
extending band . 

Buck's apparatus for fractured 
thigh 

Mode of making extension with 
the gaiter .... 

Mode of making extension with 
cravat 

Mode of making extension with 
adhesive strips . 

Mode of applying the starch- 
ed apparatus in fractured 

thigh 

1 



Fracture of the patella 



Sanborn's apparatus for frac- 
tured patella 

Same, applied .... 

Sir A. Cooper's apparatus for 
fractured patella . 

Another apparatus by same au- 
thor 

Wood's apparatus for fractured 
patella . • 

Hamilton's apparatus for frac- 
tured patella 

Lonsdale's apparatus for frac- 
tured patella 



PAGE 

461 
461 

462 

462 
462 

463 
463 

464 

465 

466 

466 
467 

467 

467 

468 

468 

468 

469 

469 
471 

473 
473 

473 

474 

474 
475 
476 



LIST OF ILLUSTRATIONS. 



XXI 



FIG. 




PAGE 




423. 


Lansdale's apparatus for frac- 




456. 




tured patella 


476 




424. 


Malgaigne's hooks for fractured 




457. 




patella .... 


477 




425. 


\ Fractures of the tibia and 
J fibula . . . 




458. 


426. 


480 




427. 


Fracture box .... 


482 


459. 


428. 


Mode of suspending the frac- 








ture box . . 


483 


460. 


429. 


Another mode of suspending 








fracture box 


483 


461. 


430. 


Starched apparatus for the leg. 


484 




431. 


Hutchinson's apparatus for frac- 




462. 




tured leg . 


484 




432. 


Neill's apparatus for fractured 




463. 




leg 


485 




433. 


Neill's apparatus for compound 




464. 




fracture of leg 


485 




434. 


Weiss 's apparatus for fracture of 




465. 




the leg .... 


486 




435. 


Weiss's apparatus modified by 








Fergusson .... 


487 


466. 


436. 


Welsh's apparatus for fractured 








leg .... 


487 


467. 


437. 


Bauer's apparatus for fractured 




468. 




leg 


487 




438. 


Pott's angular splint for frac- 




469. 




tured leg .... 


488 




439. 


Mclntyre's apparatus for frac- 




470. 




tured leg .... 


489 


471. 


440. 


Malgaigne's apparatus for frac- 




472. 




tured leg .... 


490 




441. 


Same, applied .... 


490 


473. 


442. 


Gross's tin splint for fractured leg 


491 


474. 


443. 


Wire splint for fractured leg . 


491 


475. 


444. 


Fracture of the fibula 


492 




445. 


Dupuytren's splint modified . 


493 


476. 


446. 


Dupuytren's apparatus for frac- 








tured fibula .... 


493 


477. 


447. 


Lonsdale's apparatus for frac- 








tured os calcis 


493 


478. 


448. 


Apparatus for ruptured tendo- 








Achillis .... 


495 


479. 


449 


Shoe to assist walking after dis- 








location .... 


499 


480. 


450 


Clove hitch .... 


507 




451 


Same applied .... 


507 


481. 


452 


Pulleys and iron ring 


508 


482. 


453 


Application of the pulleys 


508 


483. 


454 


Application of the rope windlass 


509 




455 


. Bloxham's dislocation tourni- 




484. 




quet 


509 





PAGE 

Double dislocation of the lower 
jaw 511 

Appearances of dislocation of 
lower jaw .... 513 

Dislocation of the sternal end 
of the clavicle forwards . 518 

Dislocation of the outer end of 
the clavicle upwards . .521 

Apparatus of Mayor for disloca- 
tion of the clavicle . . 522 

Dislocation of the shoulder 
downwards . . . .524 

Appearance of dislocation of 
shoulder downwards . . 525 

Sir A. Cooper's method of se- 
curing immobility of scapula 526 

N. R. Smith's method of reduc- 
ing dislocated shoulder . 527 

Sir A. Cooper's mode of making 
counter-extension with the 
heel 527 

Mode of reducing dislocation of 
shoulder with knee in axilla 528 

Skey's iron knob for axilla . 528 

Skey's mode of reducing dislo- 
cated shoulder . . . 528 

Mothe's method of reduction 
modified . . . .529 

Subcoracoid dislocation . . 530 

Subclavicular dislocation . 530 

Appearance of subcoracoid dis- 
location . . . .531 

Subspinous dislocation . . 531 

Dislocation of elbow backwards 533 

Appearance of dislocation of 
elbow backwards . . 533 

Mode of reducing dislocation of 
elbow 534 

Incomplete dislocation of the 
elbow outwards . . . 535 

Incomplete dislocation of the 
elbow inwards . . . 536 

Dislocation of the radius for- 
wards ..... 537 

External appearance of dislo- 
cation of radius forwards . 538 
, Dislocation of carpus backwards 540 
. Dislocation of carpus forwards 540 
, Dislocation of first phalanx of 

thumb backwards . . 542 
, Sir A. Cooper's mode of re- 
ducing dislocated thumb . 544 



XX11 



LIST OF ILLUSTRATIONS. 



FIG. 




PAGE 


PIG. 


485. 


Levis's instrument for dislocated 




510. 




phalanges .... 


544 


511 


486. 


Same, applied 


544 


512 


487. 


"Indian puzzle," employed for 




513 




the reduction of dislocation 




514 




of the phalanges . . . 


545 


515 


488. 


Dislocation of the first phalanx 








of the thumb forwards 


546 


516 


489. 


Reduction of dislocation of the 
phalanx backwards by ex- 




517. 




tension .... 


546 


518. 


490. 


Dislocation of second phalanx 








of finger backwards 


547 


519. 


491. 


Iliac dislocation, anatomical re- 




520. 




lation ..... 


548 


521. 


492. 


Iliac dislocation, external ap- 




522 




pearance .... 


548 


523 


493. 


Diagram showing application of 




524 




the flexion method in the re- 




525 




duction of dislocated hip 


550 




494. 


Method of reducing dislocated 




526. 




hip with pulleys . 


550 


527 


495. 


Sciatic dislocation, anatomical 




528 




relation .... 


551 


529. 


496. 


Sciatic dislocation, external ap- 




530. 




pearance . . 


551 


531. 


497. 


Method of reducing sciatic dis- 




532. 




location with pulleys . 


552 


533. 


498. 


Thyroid dislocation, anatomical 




534. 




relation .... 


553 


535. 


499. 


Thyroid dislocation, external 








appearance . . ... 


553 


536. 


500. 


Mode of reducing thyroid dis- 








location with pulleys . 


554 




501. 


Pubic dislocation, anatomical 




537. 




relation .... 


555 




502. 


Pubic dislocation, external ap- 




538. 




pearance .... 


555 


539. 


503. 


Mode of reducing pubic dislo- 




540. 




cation with pulleys 


555 


541. 


504. 


Dislocation of the patella out- 




542. 




wards 


556 




505. 


Dislocation of the patella in- 




543. 




wards ..... 


557 


544. 


506. 


Dislocation of the head of the 




545. 




tibia backwards . 


558 


546. 


507. 


Dislocation of the head of the 




547. 




tibia forwards 


559 


548. 


508. 


Incomplete dislocation of tibia 




549. 




outwards .... 


559 


550. 


509. 


Incomplete dislocation of tibia 




551. 




inwards .... 


559 





\ Dislocation of the foot for- 

) wards .... 561 

) Dislocation of the foot back- 

) wards . . . .562 

Dislocation of the foot inwards 563 

Reduction of dislocation of the 

foot with pulleys . .564 

Dislocation of the foot outwards 564 
Dislocation of the astragalus 

outwards .... 566 
Compound dislocation of the 

astragalus inwards . .567 
Corrigan's button cautery . 572 
Different forms of the cautery . 578 



Galvanic cauteries . . 580 



Marshall's galvanic seton . 581 
Bunsen's battery with cauteries 
attached . . . .581 

I Maisonneuve's plan of cau- 
f terization . 



>• Acupuncture needles . 

Manner of holding the bistoury 
in opening abscesses 

Manner of holding the bistoury 
in opening deep-seated ab- 
scesses .... 

Mode of holding Syme's ab- 
scess-lancet .... 

The trocar . .... 

Scalpel held as a pen 

Scalpel held as a violin -bow . 

Bistoury held as a carving-knife 

Manner of using the bistoury 
with the finger as a director 

1 



584 



Porte-moxa . . . . 585 
Seton-needle armed . . 589 

Mode of introducing the seton 590 



591 



593 



593 

594 
594 

597 
597 
598 

598 



• Different forms of incision . 599 



Knife for subcutaneous inci- 
sions 600 



LIST OF ILLUSTRATIONS. 



XX111 



552. 
553. 

554. 

555. 
556. 

557. 
558. 

559. 

560. 

561. 

562. 
563. 
564. 

565. 

566. 
567. 
568. 

569. 
570. 
571. 

572. 

573. 

574. 



575. 
576. 
577. 
578. 
579. 
580. 

581. 

582. 
583. 
584. 
585. 



f Anatomical relation of the 

•i veins in the bend of the 

t elbow .... 

Mode of holding the thumb- 
lancet in bleeding 

Spring-lancet .... 

Mode of arresting hemorrhage 
from the brachial artery 

Bleeding at the jugular vein . 

Mode of dividing the temporal 
artery in arteriotomy . 

Bandage and compress applied 
after arteriotomy 

Mode of attaching an air-pump 
to the cupping-glass . 

Cupping-glass with India-rub- 
ber ball attached . 

Scarificator .... 

Kolbe's mechanical leech 

Forceps for the upper incisors 
and cuspidati 

Forceps for the lower incisors 
and cuspidati 

Forceps for the bicuspidati 

Forceps for the lower molars . 

Forceps for the right upper mo- 
lars 

Forceps for the left upper molars 

Forceps for the last molars 

Forceps in extracting lower in- 
cisor ..... 

Forceps in extracting upper 
molars .... 

Mode of using the key in ex- 
tracting teeth 

Diagram showing the anatomi- 
cal relation of the canaliculi 
with the nasal-duct 

Anel's probe .... 

1 



Styles for dilating nasal- 
duct . . 



\ 

) 

Morgan's probe 

Flexible tube and the Eusta- 
chian catheter into which it fits 
Belloc's sound .... 
Mode of plugging the nares 
Stricture of the gullet 
Sponge probang 
Diagram showing the sizes of 
catheter .... 



PAGE 


FI8. 




586 


601 


587 


602 


588 


603 






589 


604 




605 


590 


607 


591 


607 


592 


609 


593 




594 


609 


595. 


609 


596 


613 






597. 


614 




615 


598. 


615 


599. 


615 




616 


600. 


616 


601. 


616 


602. 


617 


603. 




604. 


617 





605. 



618 





606 


619 


607 


619 


608 




609 


620 


610 


620 


611 




612 


620 




621 


613 



622 j 

623 614. 
624 

615. 
626 



Catheter showing the proper 
curve 626 

Mode of introducing the cathe- 
ter 627 

Hypertrophy of the middle 
lobe of the prostate gland . 628 

Velpeau's method of fastening 
a catheter . ... . 628 

Method of holding the female 
catheter . . . .629 

Retentive bandage for the fe- 
male catheter . . . 629 

Erichsen's mode of removing 
foreign bodies from the skin 631 

Toynbee's ear speculum . . 633 

Wilde's ear speculum . . 633 

Otoscope 633 

Instrument for removing for- 
eign bodies from the ear . 633 

Toynbee's forceps for removing 
foreign bodies from the mea- 
tus 634 

Hewson's forceps . . . 634 

Corse's instrument for remov- 
ing foreign bodies from the 
ear 634 

i Bond's gullet forceps . . 635 

Mode of introducing the forceps 

into the gullet . . . 636 
Bond's gullet hook . . .636 
Instrument for removing nee- 
dles from the gullet . . 637 
Gross's instrument for removing 
foreign bodies from the oeso- 
phagus . . . .637 
Weiss's urethral dilator . . 639 
Urethra forceps . . . 639 
Weiss's forceps . . . 640 
Instrument for removing for- 
eign bodies from the urethra 640 
Double-bladed urethra forceps 640 
Urethra forceps . . . 640 
Scoop for removing foreign 

bodies from the rectum . 641 
Mode of compressing the bra- 
chial artery .... 645 
Mode of compressing the femo- 
ral artery .... 646 
Mode of compressing the popli- 
teal artery .... 646 



XXIV 



LIST OF ILLUSTKATIONS. 



FIG. 




PAGE 


FIG. 




PAGE 


616. 


Spanish windlass . 


647 


628. 


) Mode of introducing the acu- 


617. 


Field tourniquet 


647 


629. 


j pressure needle 


. 653 


618. 


Petit's tourniquet . 


648 


630. 


Tortion of an artery 


. 655 


619. 


Tourniquet applied to the bra- 




631. 


The interrupted suture 


. 659 




chial artery .... 


648 


632. 


The continuous suture 


. 659 


620. 


Tourniquet applied to the femo- 




633. 


l Needles for twisted suture . 659 




ral artery .... 


648 


634. 






621. 


Dupuytren's compressor. 


649 


635. 


Twisted suture 


. 660 


622. 


Gross's arterial compressor 


649 


636. 


Pin-pliers 


. 660 


623. 


Ligature of an artery 


650 


637. 


India-rubber suture 


. 660 


624. 


Mode of tying a ligature 


651 


638. 


Quilled suture 


. 660 


625. 


The sailor's knot . 


651 


639. 


The serrefine . 


. 661 


626. 


Tenaculum needle, armed with 




640. 


Bullet forceps . 


. 664 




a ligature .... 


652 


641. 


Kolbe's bullet forceps 


. 664 


627. 


Physick's artery forceps . 


652 


642. 


Bullet extractors 


. 665 



ELEMENTARY OPERATIONS 



IN 



SURGERY. 



PART I. 

OF THE "APPARATUS OF DRESSING." 

By the term " Apparatus of Dressing/' or, more simply, Apparatus, 
are meant, technically, all the portions or pieces of a surgical dressing, 
with the instruments used in their application. For convenience of 
description we shall divide the apparatus into four parts : — 

1st. The instruments of dressing. 

2d. The first pieces of dressing, or those applications which are 
placed in direct contact with the skin, as lint and adhesive plaster. 

3d. The second pieces of dressing, or bandages properly so called, 
as the roller and its modifications, and intended to be placed over the 
first pieces to retain them in the situation they are designed to occupy. 

4th. Those mechanical contrivances variously called apparatus, 
mechanisms, or machines employed in the treatment of deformities, 
fractures, and dislocations. 

Surgical dressings may be defined to be the proper and regular 
application of mechanical means, or topical remedies, to parts diseased 
or injured, from internal or external causes, with a view of restoring 
them to health. 

It requires on the part of the surgeon ingenuity and dexterity only 
to be acquired by long practice to obtain all the advantages procura- 
ble from the proper and methodical application of surgical dressings, 
bandages, and apparatus. 



CHAPTER I. 

OF THE INSTRUMENTS OF DRESSING. 

In the daily routine of duty, in dressing and performing elemen- 
tary operations, experience has taught us the utility of certain instru- 
ments which, for convenience, security, and portability, are usually 
arranged upon an oblong piece of leather under little loops, and, fold- 
ing up in a compact form or packet, is called the 2>ocket-case. 
o 



34 



OF THE INSTRUMENTS OF DRESSING, 



A considerable amount of taste and judgment as to the number and 
kind of instruments, with which he fills his case, may be displayed by 
the surgeon, but we intend to limit our descriptions to those only 
which are of real practical use. 

There are two kinds of knives, scalpels and bistouries, differing from 
each other simply in the width of the blade, the former being more 
or less broad, and the latter narrow. 

Scalpels vary among themselves, not only as regards the size of 
the blade, but also in the degree of convexity of its cutting edge, 
according to the individual views, convenience, or taste of the opera- 
tors. The blades are articulated with handles of horn, ivory, or tor- 
toise shell, either fixedly, as in the ordinary operating scalpel, or 
movably. In the latter case, the handle consists of two lateral pieces 
riveted at one end with the heel of the blade, and at the other with a 
small intervening fragment of ivory to separate them at a. convenient 
distance for the reception of the blade. By this arrangement the 
cutting edge (Fig. 1) is protected, and the lateral pieces being open 

Fig. l. 



Single-bladed scalpel. 

upon both sides, front and back, the instrument may be thoroughly 
cleansed from blood or moisture which, if permitted to remain, would 
rust the blade and render it unfit for use. Upon the handle, near the 
rivet, there is an oblong slit with a little pin playing in it, to slide 
behind the apex of the heel to maintain the blade open when the 
knife is in use, so as not to risk injuring the operator's hand, or the 
patient, by any sudden and unexpected closure, or to permit the blade 
opening when it has been shut and the instrument placed in the case. 
It is the custom now, in order to diminish the number of instruments 
in the pocket-case, to rivet two blades, instead of one, to the handle, as 
seen in Fig. 2. 

Fig. 2. 




Double-bladed scalpel. 



For the purpose of operating, those scalpels are the best with the 
blade and handle immovably articulated and the lateral surfaces of 
the latter somewhat roughened, which enables the surgeon to seize 



BISTOUKIES, 



35 



them firmly, so that they are not apt to slip from his hand when 
covered with blood. The common forms of scalpels now in use are 
seen in the annexed sketch. Fig. 6 shows one with a moderately 
convex edge, the point at the summit of its axis, and the back slightly 



Fig. 3. 



Fig. 4. 



Fig. 5. 



Fig. 6. 



Fig. 7. 



Different forms of the scalpel. 

convex at the anterior part of the blade, with two narrow lateral 
facets joining behind and forming a cutting edge, which will be found, 
generally, the most convenient and useful in making incisions and 
dissections. 

The pocket-case is occasionally furnished with three or four blades 
of different sizes fitted to one handle, in such a manner that they may 
be articulated or disarticulated at pleasure, and when not in use they 
are secured, under loops, to a small piece of leather folding upon 
itself, and kept in one of the compartments of the case. 

Bistouries. — There are four forms of the bistoury in constant use, 
in the daily routine of practice : 1st. A straight (Fig. 8) and sharp - 

Fig. 8. 



=^iams<3M = 



Straight bistoury. 

pointed instrument which is exceedingly light, and well adapted for 
making neat incisions, and is preferred by French surgeons for ope- 
rating. 2d. The straight and blunt-pointed bistoury is employed 
sometimes, in the neighborhood of important arteries, nerves, and 
other organs, to avoid puncturing them when the incisions are carried 
to a considerable depth, and where, perhaps, the point of the finger 
alone guides the knife. 3d. The curved sharp-pointed bistoury (Fig. 
9) is in more continual demand by the surgeon for incising and punc- 



36 



OF THE INSTRUMENTS OF DRESSING. 



turing than any of the varieties of this instrument. It is made to act 
in most cases from within outwards, as in opening abscesses or other 

Fig. 9. 



Curved sharp-pointed bistoury. 

morbid fluid collections, slitting up sinuses and fistulas, and in in- 
cising the tissues upon a director. 4th. The last form of the bistoury 
(Fig. 10) is curved and blunt-pointed. Its utility is restricted to a 

Fig. 10. 



Curved blunt-pointed bistoury. 

small number of cases, such as relieving deep-seated strictures in 
strangulated hernia, incising subcutaneous bridles, dividing tendons, 
and laying open the skin upon the grooved director. 

Scissors. — Although not absolutely necessary, three pairs of scis- 
sors of different forms will render the pocket-case more complete and 
convenient ; they are the straight (Fig. 11), the angular (Fig. 12), and 
those curved upon the flat (Fig. 13). 

These instruments should be sharp, and their blades so riveted 
together as to enable the operator to bring their edges in contact 
perpendicularly that they may not catch, nor yet separate so far as to 
allow the tissues or linen to slip between them, and be crushed, instead 

Fig. 11. 




Straight scissors. 

of being neatly divided. The rings should be out of the axis of the 
stems and permit these to lie in close contact. 

Charriere, of Paris, has modified the manner of articulating the 
blades in the following manner : one of them is provided with a tenon 
upon its inner side, and the other with an elliptical slit, or perfora- 
tion, which receives the tenon in such a way as to preclude the possi- 
bility of their separation, however wide they may be opened. The 
advantage claimed for this plan is that the blades can be disarticulated 
at will and thoroughly cleansed ; the old arrangement not permitting 
this, the blood or fluid of any kind with which the scissors may have 
been brought in contact collects about the rivet and rusts it, and thus 



SCISSORS — RAZOR. 



37 



prevents their free play ; or, worse yet. loosens the blades to such an 
extent that their edges bruise the objects brought between them. 
Nevertheless, the tenon wears by constant use and permits the blades 

Fig. 12. 




Scissors curved cm their edge. 

to separate, so that the last objection holds also against the new 
arrangement. 

The straight scissors are generally used for cutting dressings and 
bandages ; those curved on the flat for removing any excrescences, 
as warts, &c, and for operating in cavities where straight blades could 
not act to advantage, if at all. The angular scissors, or those curved 
upon the edge, will be found convenient in dividing the tissues raised 

Fig. 13. 




Scissors curved on the flat 

upon a director; laying open fistulous canals — the angularity per- 
mitting one of their blades to be slid under the skin in a parallel 
direction. It is the proper instrument to use, also, when a roller 
bandage is to be removed. 

In using the scissors they are, commonly, held by the thumb and 
the middle or third finger being placed in their rings, while the index 
finger is extended along the side for the purpose of steadying them ; 
however, convenience and habit are the best guides in this matter. 

Razor. — It is always desirable to have a razor in the pocket-case, 
to remove the hair from those parts upon which dressings are to be 

it is an inelegant habit to use the 



applied or an operation performed 



Fig. 14. 




Razor for the pocket-case. 



operating scalpels and bistouries for this purpose, to say nothing of 

Fatty substances applied to hairy 



the damage it does their edges 



38 OF THE INSTRUMENTS OF DRESSING. 

surfaces glue the hairs together in hard and irritating knots^ or cause 
them to adhere to the dressings, rendering their removal difficult and 
painful. 

In manipulating with the razor apply its blade nearly flat to the 
part, and then by a quick sawing motion cut the hair from above 
downwards. 

Forceps. — There are two pairs of forceps in the pocket-case : the 
dressing or ring forceps and the artery forceps. 

The dressing-forceps are commonly constructed like the scissors, 
except that their anterior branches are made in the form of stems 
which are broad at their extremities and grooved transversely in five 

Fig. 15. 




Dressing-forceps. 

or six little eminences upon their inner surface, forming jaws which, 
when closed, interlock, so that a firm hold may be had upon anything 
seized by them. 

A still better form of this instrument (Fig. 15) is that modelled after 
the French polypus forceps, the branches of which cross each other in 
such a manner that the stems occupy less room, opened, than when they 
are closed. When the dressing-forceps are employed they may be 
held in the same way as the scissors. 

The artery forceps (Fig. 16) resemble those used in dissection, in 
having their blades solidly riveted to a small piece of intervening 
steel at one end, and separating at the other by their own spring. 
They are held between the thumb and the index and middle fingers ; 
and should be so constructed as to be easily closed by gentle pressure, 
for any unusual stiffness of the spring tires the fingers. The outer 

Fig. 16. 




Artery forceps, with slide. 

surfaces of the middle sections of the blades are file-cut, to prevent 
the instrument slipping from the fingers when bloody. The inner 
borders of their points are grooved transversely to enable them to 
retain any object seized ; and crossing these perpendicularly is another 
groove terminating above in a little round pit, to receive a pin or a 
needle. To secure the blades fixedly upon the object between their 
jaws, a catch-slide or spring is fitted to them. 



FORCEPS, 



39 



For "holding pins or needles in making the twisted suture the forceps 
seen in Fig. 17 are better adapted than the preceding; the slide 

Fig. 17. 




Forceps for holding pins in making twisted snture. 

presses directly upon the points of the instrument, and must, there- 
fore, necessarily cause these to grasp the pin more firmly. 

Forceps are designed to replace the fingers in situations where 
these could not be used to advantage, or where the objects are too 
small to be grasped by them. The ring forceps are used to remove 
soiled dressings from wounds, and loose fragments of bone or other 
foreign bodies from the tissues. 

The artery forceps have finer points, and are suitable for seizing 
small objects, such as pins, threads, &c, and the mouths of bleeding 
vessels for ligation and torsion, though in the latter case the points of 
the instrument are liable to be caught in the loop of the thread when 
the knot is being tied upon the artery ; to obviate this annoyance the 
forceps seen in Fig. 18 are used. They have broad and arched jaws, 

Fig. 18. 




Artery forceps with arched points. 

which throw the loop from their sloping sides upon the artery when 
the knot is drawn tight. To confer additional lightness, the points of 
the forceps are also fenestrated. 

Another form of artery forceps is seen in Fig. 19 ; they are of the 

Fig. 19. 




Artery forceps closing by their own spring. 

same shape as the former, but their blades cross each other in such a 
manner as to close by their own spring. 

Liston's bull-dog forceps have their points armed with little teeth, 
and the blades are held together by a spring, as seen in Fig. 20. 

Velpeau {Operative Surgery, vol. i. p. 92) advises the addition to the 
pocket-case of a pair of forceps armed at their extremities with three 



40 



OF THE INSTRUMENTS OF DRESSING, 
Fig. 20. 




Liston's forceps. 
Fig. 21. 




Tooth-pointed forceps. 

small mouse-like teeth, two upon one side and one upon the other, 
which can in some cases be used with extreme advantage (Fig. 21). 

Tenaculum. — The tenaculum is a delicate sharp-pointed hook with 
its heel fixed in a handle like a bistoury. It is used to draw out the 

Fig. 22. 



Tenaculum. 

mouths of bleeding vessels to be ligated, and sometimes for the torsion 

of small arteries. 

Lancets. — The thumb-lancet (Fig. 23) is a short-pointed blade with 

a cutting edge upon both sides, for 
Fi 23. a tmr( l of its length. Its heel is 

articulated with a handle, the late- 
ral halves of which, being free at 
their remote ends, are movable 
upon each other, permitting the 
instrument to be easily cleansed. 
The cutting-point varies in length ; 
and, from its shape, is sometimes 
called the oat-eared, the barley- 
eared, and the serpent-tongued 
lancet. Either of these is used 
according to the greater or less 
depth at which the vein, or collec- 
tion of matter can be reached. 
Some persons have deemed a 
Thumb-iancet. special instrument necessary for 

opening abscesses ; it is constructed 

like the ordinary thumb-lancet, but with a broader and longer blade, 

and an elongated and slightly curved point (Fig. 24). 

Special vaccinating lancets are sometimes employed; they have 

blades quite narrow, and a groove a quarter of an inch long in their 




PEOBES. — THE PORTE- MECHE. 41 

Fig. 24. 




Syme's abscess lancet. 



axis, and terminating at the point to permit the ready flow of the 
vaccine matter beneath the epidermis. 

The gum-lancet consists of a narrow stem with a curved cutting 

Fig. 25. 



Gum-lancet. 

point, and its heel riveted to a handle in the manner of the tenacu- 
lum. Its name sufficiently indicates its use. 

Probes. — Probes are delicate metallic stems for exploration, and 
should be made of silver, in order to be sufficiently tough and flexible 
to assume any shape required by the devious courses of wounds and 
fistulas. They are of three kinds — the simple, the eyed, and the 
grooved probe ; all of them have at one end a little globular enlarge- 
ment. The simple probe has the other end terminating in a sharp 
point of a prismatic shape ; the second (Fig. 26) has an eye, which 

Fig. 26. 



Simple probe. 

serves the purpose of inserting a seton, or passing a ligature; and the 
grooved probe, as its name indicates, has a narrow canal coursing half 
its length, and is employed to direct the point of a knife in laying 
open very contracted sinuses. 

The military surgeon sometimes avails himself of a cylindrical me- 
tallic stem, usually in two or three sections, and called the gunshot 

Fig. 27. 

o — c 



Gunshot probe. 

probe (Fig. 27), for exploring at greater depths than any ordinary 
probe would permit him to go. 

The Porte-meche (Fig. 28). — One may often conveniently avail 
himself of the assistance of a little instrument called the porte-meche 
for inserting threads or tents into narrow wounds, fistulas, or other 
cavities. It is simply a stem of silver, with one of its extremities 
notched or forked to hold the threads, and the other terminating in a 



42 



OF THE INSTRUMENTS OF DRESSING. 



Fig. 28. 



0* 



Porte-meche. 



little button. To use it, place the central part of the meche upon the 
fork, and draw its ends along the sides of the stem towards the button, 
which rests against the palm of the hand, while the thumb, index and 
middle fingers support the stem and the meche at the same instant. 

The Director. — This is a grooved steel stem four or five inches 
long, terminating at one end in a cul-de-sac, and at the other in a 
broad plate fissured at its centre, and by which it is supported with 
the thumb and index-finger. The split plate may be employed in 
steadying contracted bridles while they are being divided, as the 

Fig. 29. 



i 



Directors. 



fraenum of the tongue. The groove in the stem acts the part of a 
conductor for the point of a knife or scissors in slitting up sinuses. 
The point of the director is an excellent means for dividing or tearing 
through the cellular tissue over an artery, for the purpose of ligating it. 
The Spatula. — The common spatula is a narrow, thin steel plate, 
four or. five inches long, used for spreading plasters and cloths with 
cerate, and for scraping fatty or other offending matter from the skin. 
The French spatula (Fig. 30) is a much more useful instrument, and, 



Fig. 30. 



B» 



Spatula. 

like the preceding, is made of steel; one-half of its length is expanded 
into an elliptical plate, convex on one side, and with a crest running 
along the middle of the other, bounded laterally by two concave sur- 
faces ; the other end forms a stem with a transversely grooved point, 
and makes a good elevator ; the broad portion answers the same pur- 
poses as the former spatula. 

Fig. 31. 




Porte-caustic. 



The Porte-caustic (Fig. 31) is a simple hollow cylinder or tube of 
silver, vulcanized India-rubber, or ebony, to receive a stick of nitrate 
of silver, which serves a great variety of surgical purposes, as the 
curing of chronic inflammations, repressing exuberant granulations, 



NEEDLES — ARTERY NEEDL! 



43 




Surgical needles. 



such pins as are used by the entomologist, for the twisted 
suture. The needles ought to be kept bright and clean 
by smearing them with a little mercurial ointment before 
being put away. 

The exploring needle (Fig. 33) is of large size and 
grooved, mounted upon a handle which at the same time 

Fig. 33. 




Exploring needle. 

forms a sheath for it when not in use. The exploring 
trocar (Fig. 34) is simply a long needle furnished with a 
tube like the ordinary trocar. These instruments enable 
the surgeon to explore the nature of tumors, and to remove 
a specimen from their interior. The greatest discrimination 
should be exercised in employing them, as great injury 
may be clone the patient by the injudicious puncturing of 
certain morbid growths. 

The Artery Needle is a curved metallic stem, with a 
broad-eyed point, mounted upon a handle, in the manner 



Fig. 34. 

A 



and stimulating indolent ulcers. The porte-caustic, as it is usually 
furnished by the manufacturer, is in three parts, fitting together ; one 
end of the middle section supports a cleft tube of platinum, with a 
ring sliding upon it to hold the caustic, while the other contains a 
reserve supply of this article, preserved from the air by 
the cap or third section shutting it up in the tube. The 
caustic pencil should be carefully cleansed of all moisture 
before inclosing it in the case. Besides the nitrate of sil- 
ver, it will be found advantageous to have a crystal of the 
sulphate of copper, trimmed to a blunt point, in one of 
the compartments of the pocket-case. It is used in similar 
cases as the lunar caustic. 

Needles (Fig. 32). — There should always be an ample 
supply of surgical needles, both straight and curved, in the 
pocket-case; also a number of common sewing-needles, and 

Fig. 32, 




u 



OF THE FIRST PIECES OF DRESSING. 




Fig. 35. of a tenaculum. It serves the purpose of 

passing a ligature around an artery. 

Catheters (Fig. 35). — There should be at 
least two male and a female catheter in the 
pocket-case. For portability, they are made 
in short sections fitting to each other. The 
tubes are of silver, and consist of a main stem 
or body four or five inches long, the free end 
of which has two little rings soldered to its 
sides, for the attachment of a retentive band- 
age; the other end is bevelled to receive 
three different shaped beaks : the first is short 
and slightly curved, and converts the tube 
into a female catheter ; the other two are long 
and very much curved, and, being of different 
sizes, supply the surgeon respectively with a 
]STo. 7 and a No. 3 male catheter. The bevel 
upon the distal end of the main stem pre- 
vents the beaks rotating, while they are kept 
from slipping off the body by means of a 
catheters. male screw cut upon the extremity of a se- 

cond tube, c, running through the body, and 
ig in the female screws of the beaks. We shall consider the man- 
ner of using these instruments under the head of catheter ism. 
Besides the foregoing instruments, a supply of saddler's 
silk, and iron, lead, and silver suture wire, ought to be ready. 
To prevent them tangling, which they are exceedingly apt 
to do when kept in the skein or in bundles, they should be 
wound around a small piece of wood or ivory, similar to that 
seen in Fig. 36. 

The pocket-case ought to be kept in perfect order and 
efficiency, the instruments should be carefully cleansed after 
every dressing or operation, and those having cutting edges 
not permitted to become dull. 




CHAPTER II. 

OF THE FIRST PIECES OF DRESSING. 



Under this heading we propose to describe the kinds, qualities, and 
uses of certain articles which are usually placed in direct contact with 
diseased and injured surfaces, and therefrom called the "first pieces of 
dressing^ 

Lint is employed in surgical practice under three different forms — 
patent lint, charpie, and scraped lint. 



CHAKPIE. 45 

Patent Lixt is prepared by the manufacturer, and furnished the 
profession in the shape of rolls five yards long and fifteen inches wide. 
It may be described as a loosely-woven cloth of coarse hempen fibres, 
with one of its sides covered with a soft tomentose down ; the other is 
harsh, and glazed by sizing. The lint is well adapted to the various 
purposes of a surgical dressing, being alone objectionable on account 
of its expensiveness. It is used as a direct application to wounded 
surfaces, either saturated with water, warm or cold, or spread with 
cerate. When intended to act as an absorbent, all greasy substances 
should be kept from it; but for this purpose it is not nearly so good 
as charpie. Cut into pieces of various shapes and sizes, patent lint 
possesses a wide range of application, as in the preparation of com- 
presses, lining splints, as a vehicle for bringing water and medicated 
solutions in contact with the body, protecting ulcerated surfaces and 
absorbing their secretions. 

Chaepie is perhaps the best article now in use for dressing wounds, 
ulcers, and denudations. Like the preceding substance, a high price 
is asked for it by the manufacturers, by whom it is made in large quan- 
tities for surgical purposes. It may be easily prepared, as required 
by the surgeon, in the following manner: Take linen of moderate 
fineness, white, softened by use, and well washed, to free it from all 
impurities (bleaching preparations, such as chlorine and chlorinated 
lime, &c, should not be used to cleanse it); cut it into pieces three or 
four inches square; hold one of these in the left hand, and with the 
right ravel it, thread by thread, and throw them all in a heap. If the 
threads are too short, or too many of them are attempted to be re- 
moved at a time, the resulting charpie is apt to be knotty, and is illy 
fitted for contact with delicate surfaces. 

A coarser and longer-threaded charpie may be made in a similar 
mode, and used for padding splints, as an outer dressing, and such 
like purposes. 

When prepared in the way above directed, charpie forms a soft, 
light, and cottony mass, free from knots and unequal fibres. Viewed 
through a magnifying-glass, each thread is seen to be wavy, from the 
mutual pressure of the fibres by the crossing of the woof and warp, 
and is covered with little downy hooks which fasten into each other 
in every direction, holding the filaments lightly together. 

Gerdy states that new linen makes a more absorbent charpie than 
old. This may be true, if he refers to very old cloth, whose fibres 
are both condensed and cleared of the cottony down above spoken of; 
but certainly that which is only softened by wear and washing is more 
porous, and preferable to stiff and harsh-fibred new linen for preparing 
a smooth and absorbing charpie. 

With age, charpie changes color, becoming yellow, denser, and 
therefore less absorbent and more irritating than recent charpie. The 
material should be kept in a dry place, and out of the atmosphere 
of hospital wards rendered impure by the exhalations from diseased 
bodies, foul ulcers, gangrenous sores, or contagious diseases of every 
kind. Pelletan attributed the hospital gangrene which seized upon 
the wounds of a large number of the victims of the bloody days of 



46 OF THE FIEST PIECES OF DKESSING. 

the French Kevolution, lying in the Hotel Dieu of Paris, to charpie 
so exposed and used in dressing their wounds. 

Charpie is a gentle excitant of the surfaces to which it is applied, 
raises their temperature, and absorbs their secretions in a direct ratio 
with the thickness of the mass used. It takes up the serous portion 
of pus freely, and its globules less so; so that the side in contact with 
the pus will be found covered with the thickened secretion, while the 
outer surface is just moistened with the serum. The practice of 
smearing charpie with greasy matters materially interferes with, or 
entirely. arrests, absorption. 

For the purpose of answering special indications, the surgeon fre- 
quently arranges the fibres of the charpie in different manners, which 
we shall now describe. 

The Plumasseau is thus formed : Hold a mass of charpie in the 
palm of the right hand ; then, with the thumb and the radial border 
of the left, seize the, ends of the fibres, and draw them out parallel 
upon its palmar aspect. Make the plumasseau from a quarter to an 
inch thick, according to the amount of secretion to be absorbed ; then 
cut off the ends of the threads evenly, or fold them under. Its size 
and shape should vary with the dimensions and figure of the part to 
be covered ; that is, it must be round, oval, square, or quadrangular, 
according to the requirements of the case. The plumasseau is either 
applied alone, spread with cerates, or saturated with water or some 
medicated solution. Some surgeons have impregnated the charpie 
with various gases — as chlorine, carbonic acid gas, &c. — and have used 
it in certain cases with supposed advantage. 

The Gateau is nothing more than a large plumasseau, and is pre- 
pared in the same form ; but being too large to lie upon the palm of 
the hand, the threads are drawn out upon a table, the ulnar border of 
the left hand being used to retain their ends. The gateau may be 
made more expeditiously by taking a mass of charpie in the two 
hands, and moulding it with the fingers in the desired shape. The 
gateau forms a large loose mass well fitted to constitute the upper 
layer of a dressing. 

The Bullet is made by rolling charpie between the palms of the 
hands in balls varying in size from a pea to an egg, in proportion to 
the extent of the cavity to be filled. When the bullet is intended 
for the purpose of absorbing, it should be light and open-textured ; 
and on the other hand, when for pressure, as to arrest hemorrhage, it 
should be made denser by hard rolling. 

The Boll is prepared exactly in the same manner as the bullet, 
with the exception that it is given a spindle-shaped or cylin- 
drical form, and sometimes slightly compressed. It varies in size 
according to the necessities of each particular case. The purposes 
which the roll serves are chiefly to separate abraded or ulcerated 
surfaces, as the thighs and nates in intertrigo, the thighs and scrotum, 
and the labia majora when they are ulcerated. It is used also to 
keep the lips of those wounds apart, that we do not desire to have 
healed. 

The Bourdonnet consists of a number of threads rather firmly 



SPONGE TENT. 47 

rolled together between the palms, and tied together at their centre 
with a thread. It is used to make pressure at the bottom of wounds 
or cavities, and to keep the margins of any solution of continuity 
asunder. The free thread hangs externally, and enables the surgeon 
to remove the bourdonnet from its bed. 

The Pellet is a mass of charpie inclosed in a piece of muslin, and 
tied at its upper part, so as to form a sort of stopper ; or, again, the 
muslin may be introduced into any cavity, first, and then the lint 
stuffed in ; thus, a very large space with a small orifice may be readily 
filled. The pellet is employed to make pressure in hemorrhage from 
the rectum and the intercostal and internal pudic arteries. We 
should be careful in removing the pellet not to pull it swollen by the 
absorption of blood, or the secretions from the wound, but rather 
to open the muslin bag, and with a pair of forceps pick out the lint 
piece by piece. 

Tlie Tampon. — When a number of separate masses of charpie are 
thrust into a cavity or wound to plug it up, either free or inclosed in 
a little pocket of linen, a tampon is formed. So that the pellet, 
bourdonnet, roll, and bullet are tampons on a small scale when 
they are employed to make pressure upon bleeding vessels. Uterine 
hemorrhage is sometimes treated by tamponing the vagina. 

The Heche. — Place a few filaments of charpie parallel with each 
other, and tie them together at the centre with a thread, then double 
them, so that all the ends shall meet. It should be trimmed evenly, 
when you will have the common meche. 

The linen meche consists of a strip of linen an inch wide, ravelled 
at its two lateral edges into a fringe a quarter of an inch wide. 

The cotton meche is nothing more than the ordinary round lamp- 
wick. 

The meche may be had recourse to for dilating fistulous passages 
and contracted orifices. 

The Tent. — The tent is now scarcely ever used, being replaced by 
the much more elegant and convenient meche. 

Should it be desired, however, it may be formed of charpie, an old 
piece of muslin, any porous root, the gentian or flag, for instance, or 
sponge. 

If charpie is at hand, select a few fibres of it, and lay them parallel 
with each other ; then double them to bring all the ends together, and 
give the cylinder a twist between the fingers so as to impress upon the 
fibres a spiral direction and a conical form ; or a piece of soft old linen 
may be rolled into a cylinder of the desired size. 

Gentian, carrot, and calamus roots, thoroughly dried, and cut into 
pieces of the proper size and shape, will answer the purposes of a tent. 

Sponge Tent is prepared by soaking soft white sponge in melted 
yellow wax, and then allowing it to cool under pressure between two 
marble or metallic slabs. The sponge may then be fashioned with a 
knife as desired. 

Some surgeons prefer to these tents narrow strips of adhesive 
plaster rolled in little cylinders, or short pieces of a gum bougie or 
catheter. 



48 OF THE FIRST PIECES OF DRESSING. 

The ordinary object in view in employing tents is to obtain a 
dilating effect by their swelling with the absorption of the heat and 
moisture of the parts ; hence they have been used to dilate contracted 
orifices and narrowed canals. The objection to these is the painful 
pressure they sometimes exert, and the blocking in of secreted fluids. 
For procuring a gentle force, the tents made of charpie and old 
linen are to be preferred. Sponge tent acts energetically and often 
causes insupportable pain ; it is sometimes used to dilate the os uteri. 

Scraped Lint is the soft, fleecy, and light down scraped from 
the surface of old linen with a moderately dull knife. A piece of 
this kind of cloth should be stretched out upon a board, and its 
corners fastened down with tacks; or it may be held between the left 
hand of the surgeon and the hand of an assistant, while with his 
right he removes the lint with the edge of the knife. 

Viewed with a double convex lens its fibres will be found fine, 
short, and sharp pointed, and, from these circumstances, it is more 
irritating than other kinds of lint, though more absorbent. This 
property renders it an appropriate dressing in those cases of flabby 
and indolent ulcers, or of other atonic secreting surfaces which require 
gentle stimulation. 

In domestic practice, cuts and sores are sometimes dressed with the 
fine, soft down scraped from an old fur or silk hat ; it absorbs their 
moisture and forms over them an impermeable crust under which 
the healing goes on by what Macartney called the " modelling pro- 
cess." 

Cotton. — The softness, cheapness, and general diffusion of cotton 
have for a long time attracted the attention of surgeons, and induced 
them to apply it to many important surgical purposes. 

Mayor, of Lausanne, states his belief that cotton may advanta- 
geously replace all kinds of lint, while, on the other hand, Gerdy con- 
demns it in unmeasured terms, for all uses other than as aa external 
part of dressings, and for padding splints. The truth seems to lie 
between these two extremes ; for Yelpeau and Larrey have employed 
it as a direct application with considerable success and satisfaction. 
Anderson, of Glasgow, lauds cotton highly as a dressing for burns ; 
and Eoux thought it formed an excellent covering for ulcers. Every 
surgeon will readily acknowledge its usefulness as an incomparable 
article out of which the softest and downiest cushions can be made 
for supporting an injured limb, and equalizing the pressure of splints. 

Examined with a magnifier the fibres of cotton are seen to be long, 
rugged, and spirally twisted, interlacing with each other in every 
direction. It is quite absorbent, and more irritating than either 
patent lint or charpie, to which it is also now conceded to be infe- 
rior as an immediate dressing for wounds. 

We have used cotton in bed-sores, by spreading sheets of it under 
the patient, and believe that a salutary influence is exercised upon 
their surfaces by its gently stimulating action. It has one objection, 
viz., a tendency, when soaked with the secretions from the sores, to 
roll up in hard and irritating knots, which cause great discomfort to 
a patient. However, it certainly ranks next to lint in value as a 



OAKUM — TOW — WOOL — EAW SILK„ 49 

dressing, and in the absence of the latter may serve as a substitute. 
It is invaluable for maintaining an elevated temperature in parts de- 
prived of their vascular supply by the ligature of the main artery, or 
other causes. 

Cotton is found in commerce ready for use, in sheets neatly rolled 
up in cylindrical bundles. 

Oakum. — Lately this article has been much used in the treatment 
of suppurating gunshot wounds, and is particularly praised for this 
purpose by Dr. Sayers, of New York. He simply confines the oakum 
to the wounded part by a roller bandage. Seamen have for years 
been in the habit of employing it as a direct application to the wounds 
and injuries incidental to their calling. 

Oakum is prepared by tearing old tarred rope into threads ; the tar 
which permeates it confers stimulant, astringent, and antiseptic pro- 
perties, and on account of the latter quality particularly, is preferable 
to tow in cases where the secretions are fetid. 

The fibres of oakum are coarse, rough, and very unfriendly to sen- 
sitive granulating surfaces, and for this reason should generally be 
laid over a thin, interposing layer of charpie. It absorbs pus only 
moderately. 

For use the oakum is moulded with the fingers, in the form of a 
gateau of the proper size to cover the wounded part, and retained in 
position by a few lightly applied turns of a roller. 

Tow. — As an outer dressing to absorb profuse secretion and to level 
inequalities of the limbs for the application of splints, tow forms an 
excellent material. Its fibres are coarse, harsh, and irregular, which 
unfit them for the purposes to which lint is so admirably adapted. 
Various degrees of fineness are possessed by tow as found in commerce, 
the coarser varieties made from hemp should be rejected for the soft 
and elastic article prepared by the process of hatchelling flax. 

Tow is employed in the form of gateau in the same manner as 
oakum. 

AVool. — From its irritating qualities, comparative scarcity, cost, 
and general inadaptability for surgical dressings, wool can never take 
the precedence of any of the above-mentioned articles when obtain- 
able ; however, when wrought into cloth, its elasticity, and warmth- 
preserving properties highly recommend its application, in the form 
of rollers, to limbs suffering from defective circulation and nutrition, 
instead of muslin. 

Eaw Silk is here suggested rather as an attainable substitute for 
lint, tow, &c, in those countries where the article can be obtained both 
cheaply and abundantly, and in the absence of more appropriate mate- 
rials, naval medical officers cruising in the East Indies can make this 
answer as a dressing. I used it in Japan ; but the length, density, 
smoothness, and little absorbing power of its fibres did not recommend 
its continuance when a supply of other articles was on hand. 

The same remarks apply to the downy substance enveloping the 
seeds of the silk-cotton tree, a large plant of the genus Bombyx growing 
both in the East and West Indies. 

For padding splints I have made some trials with the cottony, or 
4 



60 OF THE FIRST PIECES OF DRESSING. 

rather silky matter (aigrette), attached to the seeds of the Asclepias 
Syriaca, or Milkweed, an herbaceous plant growing abundantly in the 
neglected fields throughout Pennsylvania. As it costs nothing, and 
answers as well as the finest cotton, the attention of rural practitioners 
ought to be drawn to the advantages which may be made to spring 
from its introduction into surgical practice. 

It does not irritate wounds, and will, therefore, serve as a direct 
dressing; in experiments made by me to ascertain its absorbing power, 
I found it to be equal to that of raw cotton. 

Sponge is rarely used as a dressing, though the late Dr. Valentine 
Mott entertained a high opinion of its value as a powerful absorbent, 
and as a dressing in profuse suppurations and compound fractures. 
The compression obtained by binding large pieces to flaccid and 
uneven surfaces has been highly commended by several surgeons. 
Sponge is harsh textured, and not generally agreeable to the feelings 
of a patient. The granulations developed from the surface of ulcers, 
are apt to shoot into its pores, and thus render the removal of the 
dressing both injurious and painful. 

Moss.— A fine quality of moss, in emergencies, has been used as a 
dressing ; and in countries where it grows abundantly upon the trunks 
and limbs of trees, as along the banks of the Mississippi Eiver, it may 
be made available for filling up inequalities of the surface of the 
body, and for making soft cushions to be used in the treatment of 
fractures. 

Cat's-tail, or Typha (Typha latifolia). — Cat's-tail has been for a 
long time employed in domestic practice, in some parts of Europe, as 
a substitute for cotton in burns, ulcers, and wounds. It is prepared 
by beating the cylindrical tops of the flag against the edge of a board, 
whereby a soft and whitish brown, downy, porous matter is obtained. 
It absorbs readily, but the fibres are short and sharp, and often pro- 
duce considerable irritation of the wound to which it is applied, and 
they adhere so tenaciously to them as to render their removal difficult. 

The typha grows abundantly in the marshes throughout the South- 
ern States, and is used by the country people for making beds and 
pillows. At the temporary naval hospital, located during the late 
war at the delta of the Mississippi Eiver, where this flag grows in 
the greatest plenty, during a period of great scarcity of surgical 
dressings, soft pillows for fractured limbs to repose upon, pads for 
splints, and a variety of useful articles, were prepared from cat's-tail. 

Amadou (spunk, or punk). — Amadou and spunk are two porous, 
fungous vegetable growths, found adhering to, and deriving their 
support from the juices of the oak, birch, willow, and other trees, 
and have been at times highly commended as surgical dressings. 
Mr. Wetherfield (Lond. Med. Gaz., 1841) states that the amadou or 
German tinder forms an excellent elastic medium for applying support 
and pressure, and as a defence to tender and delicate parts, as in 
the form of a graduated compress in umbilical hernia of new-born 
infants, and as a compress over fistulous ulcers of the groin. It does 
not lose its elasticity like lint. In preparing it we select such pieces as 
are firm, smooth, and of uniform density, cut them in slices, and then 



METALLIC PLATES. — COMPEESSES. 51 

by beating with, a mallet render them soft and pliant. Kecamier's 
plan of employing it in the treatment of cancer will be considered 
farther on. 

Bean. — We are indebted to Dr. J. Ehea Barton, for the introduc- 
tion of bran into surgical practice ; he generally used it in compound 
fractures of the leg, but it may be made available in the treatment of 
wounds of the soft parts. It is an elegant, light, and cool dressing, 
and particularly useful in hot weather. The bran should be heaped 
up over the broken limb contained in a fracture box, so that the flies 
cannot deposit their ova in the wounds, and produce maggots. 

Sawdust. — I have used moderately coarse pine sawdust with the 
most pleasing results, in the same manner as the bran, and think, after 
a considerable experience, that as a cool, cheap, and very absorbent 
article, we know of no substance superior to it for forming a bed upon 
which to rest profusely suppurating stumps. About a quart of the 
dust may be spread upon a square piece of muslin, the stump placed 
upon it, and the ends reflected over the limb and pinned together. 
In this manner one dressing will generally do for a whole day, no . 
inconsiderable advantage in an overcrowded hospital, near the battle 
ground, or with a small number of medical officers, a condition of 
things not very uncommon during the late war. 

Metallic Plates. — In the treatment of flabby ulcers, and wounds 
requiring some stimulation, metallic plates have been tried, particu- 
larly those of tin, or tin, antimony and lead, or simply lead, such as 
are to be found in tea-boxes. We obtain the advantages of compres- 
sion, and of the chemical action of the soluble salts formed upon the 
surfaces of the plates, by the contact with the secretions. Doubtless 
the electrical currents, which are always developed by such combi- 
nations, may have a share in their beneficial influence. 

The metallic plates are simply cut and bent into the appropriate 
size and shape of the surface to be covered, a layer of lint then placed 
over them to absorb the secretions, and the whole confined by turns 
of a roller bandage. 

Compresses. — -It will be useful to have square pieces of muslin, 
linen, and flannel at hand, for the purpose of making those compresses 
of various forms which the surgeon commonly avails himself of in 
dressing. For immediate contact with wounds, the material should 
be soft, and partially worn linen ; flannel may be used in those cases 
where its properties of elasticity and absorbability are required. It 
will also be economical, and answer just as well, to employ muslin for 
equalizing the surfaces of parts, and where the skin is unbroken. 

Besides these materials, raw cotton, tow, and other similar articles 
are sometimes made use of as compresses. 

A compress answers other indications than mere compression, which 
its etymological import would seem to imply. It may be simply pro- 
tective, as when we place a layer of soft linen between two opposing 
surfaces to get rid of the ill effects of friction, or cover a wound to 
shield it from external irritants ; or to ward off the pressure of splints ; 
again a compress may be said to be retentive only when it holds other 
dressings in place. 



52 



OF THE FIEST PIECES OF DRESSING. 



Compresses have been divided by Velpeau into three classes, the 
simple, the split, and the folded. 

1. Simple Compresses. — The square or ordinary compress is formed 
by folding a piece of cloth, with a length of double its breadth, upon 
itself; all its sides are equal. 

When the square is folded diagonally so as to bring two of its angles 
together, the triangular compress results ; then by placing the apex of 
the latter upon its base, and folding once, the cravat compress is 
formed. 

The square doubled once, gives the oblong compress, and this folded 
again, the "longuette" compress. 

The perforated compress is prepared by piercing a piece of cloth with 
numerous holes, either with the points of the scissors, or a punch 
which removes small circular bits; the latter object may also be more 
conveniently and expeditiously accomplished with the edges of the 
scissors : holding the cloth in the left hand, and shoving up small 
folds with the point of the index finger, clip them off. This compress 
is usually spread with cerate to prevent other dressings adhering to 
the wound, and necessitating painful tractions for their removal. An- 
other of its advantages is to allow the free emission of pus. 

The fenestrated compress results from the cutting out of a piece of 
cloth, of an oval, square, or triangular shape near the centre of the 
muslin. 

This is used, sometimes, to remove hurtful pressure from any part 
of the surface, as in burns and corns ; to limit the action of caustics, 
and to dress certain ulcers. 

When the square compress is twice folded, and the free angles re- 
moved in the direction of a curved line between the upper and lower 
angles, the round compress results, which may then be either perfo- 
rated, fenestrated, or fringed, so as to allow its edges to adapt itself 
accurately to the irregular outlines of any part. 

2. Split Compresses are formed by making slits in the sides, centre, 
on ends of strips of cloth of different widths and lengths. They are 
denominated the button-hole, the single-split, the double-split, the 
many-split, and sling-compresses, the half Maltese cross, and Maltese 
cross. The button-hole compress has simply a slit in its centre ; the 
single-split, or compress with two tails, is a piece of muslin slit up from 

one end to its centre; the double-split, 
as its name indicates, is divided in the 
same manner by two slits, into three 
tails. The two latter compresses are 
more commonly called retractors, and 
are used almost exclusively in amputa- 
tions to press back the soft parts while 
the bones are being sawed through ; 
the former when the limb has a single 
bone, and the latter compress when 
there are two bones. The many-split 
compress is prepared by slitting the 
two sides of a piece of muslin into a 



Fig. 37. 










- — 


""'111! 


jiilihs 


" «-flll/ 


— "iwnpr 



If 



COMPKESSES 



53 



Fig. 38. 



number of tails (Fig. 37), leaving an intermediate uncut portion or 
body. A modification of this is what is known as the bandage of 
Scultetus, consisting of separate strips overlapping each other a half 
or two-thirds of their width. When these strips are tacked together 
with thread and needle along their middle, Pott's bandage is formed. 

The eighteen-tailed bandage, so called by Yerduc, consists of three 
pieces of muslin, equal in size and of the desired width, laid one upon 
another and fastened along the centre with thread and needle; then 
with the scissors each of its two sides is split into three tails. The 
many-tailed bandage employed by Dupuytren was made of nine sepa- 
rate strips, sewed together at their centre, after having been imbri- 
cated in the usual manner. 

These different forms of the many-tailed bandage have been chiefly 
employed in making compression upon the limbs after having been 
fractured, and before the application of the other portions of the dress- 
ing ; although, in many other cases, they will be found exceedingly 
neat and convenient to retain poultices, or other dressings upon dis- 
eased or injured extremities. The bandage of Scultetus is particularly 
adapted to this purpose, for the reason that any portion of it, when 
soiled, may be removed without disturbing the rest. Their mode of 
application is the same, viz : to spread the bandage out upon the bed, 
and then to lay the limb upon it 
and bring up the strips alternately 
from side to side, imbricating them 
smoothly, until the leg, or whatever 
part it may be, is covered in. 

When applied moist for the pur- 
pose of making compression, the 
surgeon cannot watch them too nar- 
rowly; for the most disastrous con- 
sequences have, on several occa- 
sions, resulted from their producing 
excessive constriction, either by the 
subsequent swelling of the parts on 
which they are placed, or by the 
contraction of the bandage itself, or 
both causes combined. 

The sling -compress is a long strip 
of muslin or other material, divided 
from each of its extremities to 
within three or four inches of the 
centre. 

It is principally used in the treat- 
ment of fractures of the lower jaw, 
and for confining dressings to the 
joints. 

The half Maltese cross is formed 
by folding a square compress upon itself, and cutting with the scissors 
diagonally from either of the corners formed by the free angles, 
towards the centre of the opposite folded side. 




Application of the bandage of Scultetus. 



54 



OF THE FIRST PIECES OF DRESSING, 



Fig. 39. 




The Maltese cross. 



Fig. 40. 



The "half Maltese cross is sometimes employed to retain dressings 
upon the shoulder after amputation. 

The Maltese cross (Fig. 39), in like manner, may be made from 
a square compress folded twice upon itself 
in opposite directions, by cutting diagonally 
from the corner where all the free angles 
meet, towards the opposite folded angle and 
within a short distance of it. 

This compress is had recourse to as a reten- 
tive of other dressings upon stumps after 
amputation, and also upon the mamma. 

The fringed compress is a slip of linen from 
a few lines to an inch in width, incised upon one 
border only into a sort of fringe. It is spread 
with cerate, and applied to the circumference of wounds, with its 
points outwards to prevent the charpie, lint, or other dressings adher- 
ing to them. 

3. Folded compresses are prepared by folding layer after layer of 
lint, muslin, or linen upon each other in different manners. 

When these folds are of equal width, it is called the regular graduated 
compress; when, on the contrary, the folds are 
shortened upon one side, the single graduated 
compress (Fig. 40) results; and when the folds 
gradually diminish in width upon both sides, we 
obtain the double graduated compress (Fig. 41). 

The pyramidal compress is made by piling up 
square pieces of any kind of cloth upon each 
other, each being smaller than its predecessor, 
until a sufficient thickness is obtained. If these 
pieces are round, the compress will of course be 
conical. 

These compresses are useful when firm pres- 
sure is required either over a given point, line, 
or limited area; as, for instance, to restrain hemorrhage from the 
temporal and brachial arteries after being wounded in the operation 
of bleeding, or from the arteries of the palmar arch ; to exercise 
compression upon morbid growths, aneurisms, and along the course 
of fistulous canals, or over abnormal cavities; and to force from 
their nidus pus or other diseased secretions. 

Often for the purpose of retaining dressings upon the body, con- 
fining fracture apparatus, securing the limbs of patients about to 
undergo certain surgical operations, such as lithotomy, threads, cords, 
straps, and strips of muslin are employed by the surgeon. They will 
be considered in their appropriate places, throughout this work, in con- 
nection with the bandages, apparatus, instruments, and surgical pro- 
cedures to which they specially appertain. 

Bandages are secured by means of pins and threads ; and as the 
latter are connected together by knots, some of which are in frequent 
use by the surgeon, it may not be inappropriate to give figures of 
them. 




Folded compresses. 



COMPRESSES. — KNOTS 



55 



The surgeon's knot is seen in Fig. 42, and was formerly employed 
when a thread was tied around an artery. The single bow knot (Fig. 



Fig. 42. 



Fig. 43. 



Fig. 44. 






43) and the double bow knot (Fig. 44) are in constant use for fastening 
the muslin strips around fracture apparatus, and the threads securing 
the little bandages about the fingers and toes. The single knot (Fig. 
45) and the double knot (Fig. 46) are used for like purposes. 



Fig. 45. 



Fig. 46. 



Fig. 47. 






The loop knot (Fig. 47) will answer to arrest the venous circulation 
during venesection, and enables the operator to graduate the com- 
pression instantly and accurately. 

' The packer's knot (Fig. 48) is the one formed over the temple by 
the knotted bandage of the head. 

The clove hitch (Fig. 49), used in applying the extending bands for 



Fig. 48. 



Fig. 49. 



Fig. 50. 






the reduction of dislocations, consists, as seen in the figure, of two 
packer's knots laid together. 

The single noose (Fig. 50) and double noose (Fig. 51) are employed 
by the surgeon to secure the hands and feet of a patient about to 
undergo the operation of lithotomy. 

The reef or sailor's knot (Fig. 52) is the one mostly used by surgeons 
of the present day for ligaturing arteries instead of the surgeon's knot, 



56 



OF THE FIRST PIECES OF DRESSING, 



for the reason of its less liability to slip, and the certainty with which 
it closes the arterial canal. The case of Chopart, as related by Boyer, 



Fis. 51. 



Fig. 52. 



Fig. 53. 






is well known : that distinguished surgeon lost a patient from hemor- 
rhage, in operating for popliteal aneurism, after three ligatures had 
been placed upon the artery and tied with the surgeon's knot. An 
examination showed the vessel to be healthy, but not closed by either 
of the knots. 

Fig. 53 shows the weaver's knot 



Figs. 54 and 55 are forms of the 



Fig. 54. 



Fig. 55. 



Fig. 56. 



Fig. 57. 







simple slip knot; Figs. 56 and 57 are the double-knotted and looped, and 
the crossed slip-knots. 

Adhesive Plaster. — This article is of the utmost importance to 
the surgeon, being constantly in demand for the treatment of various 
diseases and injuries which are always presenting themselves in the 
daily routine of practice. It is now supplied the profession by manu- 
facturing druggists in rolled sheets ten yards long and sixteen inches 
wide. The mode of preparation consists in spreading, by means of 
machinery, the emplastrum resinae of the Pharmacopoeia (a compound 
of lead plaster and resin in the proportion of six parts of the former 
to one of the latter) upon sheets of muslin or linen. 

Ordinarily the plaster is employed in strips, yet for special purposes 
it may be cut with the scissors into any shape that may be demanded. 
The strips should be severed evenly and smoothly, and, to attain this 
object, the best plan will be to unroll the sheet to the extent required 
by the length of the strips, and stretch it, by an assistant taking charge 



ADHESIVE PLASTER. 57 

of the roll, and the surgeon of its free end with the left hand, in such 
a manner that the thumb and index finger support the extremity of 
the strip, while the middle and index fingers uphold that part of the 
sheet beyond. Then with the scissors make a small cut into the 
border of the plaster, between the fingers, and holding their blades 
half open, press them along the cloth towards the assistant. 

Although it is customary, when the roll is sufficiently ample, to cut 
the plaster crosswise, or in the woof, yet it is always preferable to 
follow the warp, or the large threads running lengthwise, for the 
reason that strips prepared in the latter way yield less to an extending 
force, and in a more uniform manner. In fact, where there is much 
resistance expected they should be made in no other way. 

The strips thus provided, to prevent any giving, ought to be sepa- 
rately stretched before being applied, and then warmed to enable 
them to adhere immediately to the skin. A moderately long and 
narrow strip may be sufficiently warmed by drawing it rapidly 
through the fingers. The flame of a candle will answer the same 
purpose, but the strip is apt to be blackened by the carbonaceous 
matters of the flame. The neatest, best, and most convenient plan of 
all is to soften the plaster by applying, for a few moments, the backs 
of the strips to a tin vessel filled with hot water. 

Adhesive plaster is adapted to a great variety of cases, and serves 
many useful purposes ; among others, to retain dressings, splints, lint, 
and compresses upon the surface ; to make compression, and to exer- 
cise a slightly stimulating effect upon ulcers of the extremities, 
chronic swellings of the joints, and upon indolent tumors ; sometimes 
it forms the whole of the retentive apparatus in certain fractures. 

The stimulating effects of ordinary plaster sometimes render it an 
objectionable dressing in fresh wounds, and where the integuments are 
exceedingly sensitive, as they occasionally are ; under such circum- 
stances it may induce erythema, or even erysipelas. To obviate, in a 
measure, the irritation, Mr. Baynton employed a plaster containing 
only six drachms of resin to the pound of lead-plaster. With the 
same view, M. Herpin recommends the addition of the tannate of lead, 
the proportion of which should not exceed one-twentieth. 

When properly made, and fit for surgical use, the plaster should 
not crack or drop off the muslin in flakes, or adhere to the skin when 
the strips are removed. The plaster may be rendered more pliable, 
and prevented from cracking in very cold weather, by the addition of 
a small proportion of soap, which is far preferable to those cheaper 
and more irritating articles, sometimes added for this purpose, Bur- 
gundy pitch and oil of turpentine. 

An adhesive plaster, prepared with the latter substance, was once 
supplied a hospital under my charge during the late war ; and after 
three or four trials I was compelled to abandon its use in consequence 
of its irritating qualities. As age diminishes its adhesiveness, the sup- 
ply should often be replenished. 

After the strips have been removed the surface may be cleared from 
all adhering matters with a sponge moistened with the oil of turpen- 



58 OF THE FIRST PIECES OF DRESSING. 

tine, and when the oil has been cleared off by castile soap and water, 
the parts may be dried with a soft towel. 

Isinglass Plaster was brought into notice by Mr. Liston, who 
says: "Of late, I have greatly dispensed with stitches and the com- 
mon adhesive plaster, using, instead of the latter, slips of glazed ribbon 
smeared with a saturated solution of isinglass in brandy, which is 
much less irritating and more tenacious than the common adhesive 
compost." 

Subsequently, for the ribbon he substituted the peritoneal covering 
of the caecum of the ox, rubbed down and polished. 

As now found in the shops it is in rolled sheets, three yards long and 
eight inches wide. Should the surgeon desire to make it himself, the 
following is the formula. Moisten one ounce of pure isinglass (the 
dried swimming bladder of several species of fish belonging to the 
genus Acipenser) with two ounces of water, and permit it to stand 
until it is quite soft ; then add three and a half ounces of rectified 
spirits, previously mixed with one and a half ounce of water. Place 
the vessel in boiling water until the solution is complete, and about 
the consistence of jelly, when it is ready for use. Now spread the 
oiled silk upon a table, tack down its ends, and with a brush apply 
the solution to its surface ; when this is dry, another coat may be laid 
on and permitted to dry. The plaster is then fit for use. 

The advantages claimed for it are that it is unirritating ; possess- 
ing some degree of translucency, the parts beneath may be always 
inspected, and finally, it does not soften in extremely warm weather. 
The latter quality will render it a valuable article to the naval sur- 
geon cruising in hot clirnates. The drawback to its general use will 
be the facility with which it is loosened by the contact of the warm 
secretions of the parts to which it is applied. 

The mode of using it is to cut the plaster in strips, and, after moist- 
ening their gummed sides with a sponge squeezed out of hot water, 
lay them on as you would the ordinary adhesive strips. 

Collodion. — This was first suggested as an agglutinative by Mr. 
Maynard, of Boston, a medical student. It is a solution obtained by 
dissolving gun-cotton, on pyroxylin, in a mixture of rectified ether and 
alcohol, in the proportion of about 16 parts of the former to one of the 
latter. 

When applied to the surface it produces, a sensation of coolness by 
the evaporation of the ether, and leaves behind a translucent, con- 
tractile, and adhesive film. To prevent the puckering up of the skin, 
which follows the application of the collodion, it has been suggested 
that one part of the oil of turpentine be added to every twenty of 
ether. Guersent, with the same view of conferring the desirable pro- 
perties of softness and elasticity upon collodion, recommended the 
addition of castor oil in the proportion of two parts to thirty of the 
former. 

It is used to approximate the edges of wounds, to close the eyelids 
after operations upon the eyes, and as a compressing agent in discus- 
sing indolent buboes and chronic tumors. 

Mr. Latour has proposed the following formula for the treatment of 



STYPTIC COLLOID. 59 

superficial inflammations : Collodion, 46 grains ; Venice turpentine, 23 
grains ; castor oil, 8 grains. This is to be applied over the whole of 
the diseased surface. His theory is, that the contact of the air is an 
indispensable element in calorification, and he seeks, therefore, to shield 
the inflamed part with an impenetrable coating of three or four lay- 
ers of collodion, put on with a camel's hair brush. A similar applica- 
tion is also used with great success, rarely irritating the skin : Collo- 
dion, 30 parts ; old castor oil, 2 parts. 

Either of these dressings is easily detached by a linseed poultice. 

M. Arran, observing the utility of the salts of iron in erysipelas, in 
order to facilitate their application, combined them with collodion, 
forming a preparation which united the compressive and astringent 
effects. It consists of equal parts of collodion and ethereal tincture 
of perchloride of iron. It is more supple and resisting than the ordi- 
nary film of collodion, and adheres more tenaciously than it to the 
skin. 

M. Yalette, of Lyons, believes it to be a powerful hemostatic, and 
Mr. J. H. Tucker effectually controlled the hemorrhage from leech- 
bites with it. 

The mode of application is simple. The collodion is placed upon the 
skin, previously carefully cleansed and dried, with a camel's hair 
brush ; or, if a firmer bond of union is required than can be obtained 
by the collodial film, a piece of lint or a few threads of charpie 
soaked in the solution may be laid over the wound. 

Chloropercha is similar in its properties to collodion, and is pre- 
pared by dissolving gutta-percha in chloroform. 

Water-glass. — Kuchenmeister has recently introduced to the 
notice of the profession a new adhesive compound which he states 
will form an impermeable film, as well as modify the vital action by 
virtue of its alkalinity. His formula is the following: powdered 
quartz 15 parts; caustic potassa 10 parts; charcoal 1 part. Mix and 
melt them together, and then add to the mixture after cooling five 
pints of water, and boil the liquid to a syrupy consistence, when it 
is ready for use. 

Dr. Miller, as a succedaneum for collodion, proposes a solution of 
shellac in highly rectified alcohol so as to have a gelatinous consistence. 

An agglutinative may be extemporized by mixing flour and white 
of eggs into a paste, and spreading this upon strips of muslin or linen. 

"Styptic Colloid." — Mr. B. W'. Eichardson, of London, has recently 
called attention to the advantages of a compound fluid for instant and 
ready use in dressing wounded surfaces, which he has designated as 
" styptic colloid." 

It is prepared by digesting in absolute alcohol for several days the 
purest tannin that can be obtained ; then absolute ether is added until 
the whole of the thick alcoholic mixture is rendered quite fluid ; 
xyloidine, or gun-cotton, is put in next until it ceases to be readily dis- 
solved, and to confer an agreeable odor upon the mixture a little 
tincture of benzoin is finally added. 

The solution is now ready for use and can be applied either with a 



60 OF THE FIKST PIECES OF DKESSING. 

brush, or mixed with an equal quantity of ether ; it can be used in the 
form of spray. 

The " styptic colloid" acts by the tannin in its composition entering 
into combination with the albumen of the blood or secretions of the 
wound or sore, forming an impermeable coating upon the part under 
which the healing process may go on much in the same manner as it 
does in subcutaneous wounds. 

As to the mode of applying the fluid it is sufficiently simple ; sup- 
posing the case to be one of an open wound, the two flaps of an 
amputation, for instance, the parts should be brought together and 
sustained by four or five fine sutures. In a wineglass tease out finely 
a little cotton wool and saturate it with the styptic solution ; apply 
this solution with a camel's hair brush over the surface of the closed 
wound, letting it lie between its edges. Next take the cotton up 
with a pair of forceps and lay a seam of it half an inch wide and 
the eighth of an inch in thickness over the line of the incision. Upon 
this another layer of the solution is put, and when dry cover it with a 
little dry cotton, and finally secure the whole with a roller bandage. 

The " styptic colloid" may be used as a dressing in recent wounds, 
hemorrhages, ulcers, cancerous sores, &c. 

" In no case," observes Mr. Eichardson, "need there be any fear that 
irritation will follow the application of the solution, on the contrary, 
the action of it is so purely negative that it might be considered a 
sedative. It is not such in the technical sense of the term, but it so 
effectually covers the wounded and susceptible surfaces as to maintain 
what is virtually a sedative influence:" though in wounds to be closed 
by first intention it is not good to leave the styptic in large quantities 
between their margins, as it sometimes produces friction and so causes 
evolution of heat and pain. 

In small wounds one dressing will be all that is necessary, and the 
styptic film will be thrown off in the process of cure. Even in larger 
wounds it will be advisable to leave the dressing undisturbed until 
the parts are thoroughly healed, unless for some urgent reason. 

As the dressing is insoluble in water either hot or cold, that fluid 
should not be employed in its removal, but a mixture of alcohol and 
ether, or equal parts of absolute alcohol and distilled water, warmed 
a little above the temperature of the body. 

Besides this simple form of " styptic colloid" this fluid combines 
well with other medicinal substances ; with creasote it forms a com- 
pound more decidedly antiseptic, and aids in solidifying the albumen 
more thoroughly ; it produces, however, some degree of irritation. The 
proportion is one minim of creasote to two drachms of the solution. 

Carbolic acid acts similarly to the creasote, and may be combined 
in the proportion of five grains of the acid to two drachms of the 
" styptic colloid." 

Where there are purulent or fetid discharges from a surface sur- 
rounded with indurated tissue, iodine may be added with decided 
advantage ; from five to seven grains may be got into a quarter-ounce 
of the solution. The iodine produces no irritation. 

The compounds of iodine, as the iodide of cadmium, potassium and 



THE SURGICAL WALLET. 61 

ammonium, the bichloride of mercury and the chloride of zinc are 
also taken up by the styptic fluid. 

Morphia and the other narcotic alkaloids are soluble in the fluid, 
and either of them may be used according to the indications presented. 

Two to four grains of cantbaridine, dissolved with the aid of a 
little chloroform in a fluidounce of the liquid, will furnish an epis- 
pastic compound. 

The Surgical Tray. — For convenience, in the daily routine of 
duty, the surgeon having charge of the surgical service of a military or 
civil hospital, generally brings together, in what is called the " surgical 
tray," certain instruments and dressings, which he may be called upon 
to use at any moment. 

The one employed by me was a simple tray 2J feet long, 20 inches 
wide, and 3 inches deep, divided into compartments of different sizes, 
and containing a number of roller bandages of various lengths, seve- 
ral kinds of compresses, pieces of muslin and linen, towels, adhesive 
strips, lint, charpie and ligatures ; other divisions received the pocket 
case, catheters, bougies, and pin-cushion. Three cups were neatly 
fixed in one end for holding a small quantity of whiskey, turpentine, 
and sweet oil. A quantity of fine sponges and a bottle of camphora- 
ted tincture of soap completed the supply. A brass hoop, spanning 
the tray from side to side, served the purpose of a handle. 

The Surgical Wallet. — As medical officers of the navy were 
called upon, during the late war, occasionally to leave their ships with 
boat expeditions on the coast, or up the narrow rivers of the South, 
it became necessary to have certain instruments and dressings arranged 
in a compact form for transportation, inasmuch as the instruments 
allowed to ships-of-war are injudiciously crowded into one unwieldy 
case, which it would not be desirable to risk, by loss of the boats, or 
any other casualty, and thus deprive them, perhaps, of every surgical 
instrument by a single unforeseen accident. 

The boats, also, on such occasions, are generally crowded, and, there- 
fore, very awkward places for a heavy and bulky surgical case. 

Having felt the need of such an arrangement, I had a surgical 
wallet constructed, consisting of a piece of strong leather three feet 
long and fourteen inches wide, folding up like the ordinary pocket 
case, and containing the following articles : two pint-flasks, with screw 
caps similar to the pocket-flask, the one containing chloroform and 
the other brandy ; a half pint flask of aqua ammonia ; a square block 
of wood excavated upon its surface to receive an amputating knife, a 
small saw, and a pair of bone forceps, one movable handle answering 
for the former instruments ; three screws and six field tourniquets ; 
twelve roller bandages ; four yards of muslin, a lot of Maltese crosses, 
and other compresses; six yards of adhesive plaster; twelve short 
splints; one box of simple cerate; and the pocket-case. When the 
wallet is rolled up, a strap is hooked to both of its ends, by which it 
can be slung over the shoulders or carried in the hand. 

Every ship-of-war should be provided with such a wallet, ready at 
any moment for transportation, should the surgeon be called to render 
assistance at a distance. 



62 ON THE USE OF SOME TOPICAL REMEDIES. 



CHAPTER III. 

ON THE USE OF SOME TOPICAL REMEDIES. 

The remedies now to be described are applied either to the skin, 
or to the mncous membranes continuous with it, and' lining the 
entrances of the several interior cavities. 

They act either locally upon the parts to which they are applied, or 
are absorbed, and exert an influence upon the economy at large. In 
the latter instance, the remedy may either be brought into contact 
with the epidermis, or, this being removed, with the dermis ; or, again, 
with the cellular tissue beneath the skin, by hypodermic injection. 

This wide range of application of these topical remedies will at 
once, suggest and justly, too, that they are both numerous and capa- 
ble of being employed in a great variety of forms and combinations ; 
and it will be our endeavor in this place to consider as many of these 
as are in daily use and of real practical value. 

Cerates. — "These are unctuous substances, consisting of oil or 
lard mixed with wax, spermaceti, or resin, to which various medica- 
ments are frequently added. Their consistence, which is intermediate 
between that of ointments and of plasters, is such that they may be 
spread at ordinary temperatures upon linen, by means of a spatula, 
and do not melt or run when applied to the skin." ( U. S. D.) 

The simple cerate of the Pharmacopoeia, consisting of lard and white 
wax, is the one most commonly used in the treatment of surgical dis- 
eases, and when spread upon linen, constitutes what is known under 
the name of " the simple dressing." 

When applied to wounds, it should be smeared sparingly upon the 
fringed or perforated compresses, for too much will convert a very 
cleanly dressing into a very uncleanly one ; the fatty matter which clings 
in crusts to the margins of the sores becoming rancid and irritating. 

Should charpie or lint be intended to act as absorbents, a perfo- 
rated and cerated piece of linen may be interposed between them and 
the secreting surface, for these materials themselves, covered with 
greasy matter, are but indifferent absorbents. 

If it is desired to obtain the stimulating effects of the charpie, as 
well as the absorbent, it may be placed in direct contact with the 
wound which has its edges previously protected by the greased fringed 
compress. 

Simple cerate is sometimes employed with frictions, to soften the 
skin, and to render parts more supple, in such cases as stiffened joints, 
contracted tendons, and rigidity of the integuments. 

Its bland qualities recommend it, when spread upon soft linen, as an 
application to .surfaces subjected to pressure, or excoriated. Such 
cases we meet with in patients confined for a long time upon their 



CERATES. 63 

backs in consequence of fractures of the bones of the spine and lower 
extremities, and in whom the shoulders, buttocks, and sacrum often 
become extremely tender. 

To the cerate, opium, belladonna, iodine, iodide of potassium, or 
other active medicaments are occasionally added to answer special in- 
dications. Combined with the solution of the subacetate of lead, it is 
much used in the treatment of burns and scalds, and the ulcers left 
by blisters. 

The cerate thus modified by these combinations may be applied, 
spread upon linen, or rubbed into the part with the hand, the latter 
plan being adopted if the object is to obtain the resolutions of chronic 
enlargements of the joints, or of glandular swellings. 

Cerates should be perfectly bland and sweet ; by long keeping they 
are apt to become rancid and extremely irritating. It has been re- 
commended to use rancid cerate as a dressing for flabby granulating 
sores needing stimulation. 

The following formulas for extemporaneous cerates will be found 
useful by the practitioner: — 

R. — Calaminae praep. 3"] > 
Camphoi-se gr. x ; 
Cerati simplicis §ij. Misce. 

This is a mild astringent and stimulant, and may be used in super- 
ficial ulcerations produced by burns, acrid secretions, chafing, or other 
causes. 

R. — Cerati plumbi subacetatis, 
Cerati simplicis, aa 3SS ; 
Hydrarg. chlo. mit., 
Pulv. opii, aa 3j. Misce. 

Used in excoriations, ulcers, burns, scalds, chilblains, and chancres. 
(Dr. Parrish.) 

R. — Resinse §j ; 

Cerae flavae 3 ij ; 
Adipis ^ij. Misce. 

For burns. (Dr. Physick.) 

R.— Hydrarg. praecip. albi 5lj 5 
Cerat. simpl. §j. Misce. 

A valuable application in venereal ulcers, porrigo, and other cuta- 
neous diseases. 

R. — Hydrarg. nitrico-oxidi £j ; 
Cerat. simpl. §j. Misce. 

A common application to ulcers and sores in general. 

R. — Unguenti hydrarg. nitr. 3j 5 
Cerat. simpl. §ss. Misce. 

A celebrated application to the edges of the eyelids in chronic 
ophthalmia and opacities of the cornea; it is used also as a dressing 
for ulcers and sore nipples. 

R. — Unguenti hydrarg., 
Cerat. saponis, aa ^j ; 
Camphorae 9ij. Misce. 

For discussing hardness of the tissues and indurated swellings, and 
when rubbed along the course of the urethra relieves chordee. 



64 ON THE USE OF SOME TOPICAL REMEDIES. 

R. — Cerati resinse comp. ^j (Deshler's salve) ; 
Adipis 5ij- Misce. 

For healing ulcers following burns. 

R. — Cerse albse %iv ; 
Olei olivse §j ; 
Aceti destillati fgij. Misce. 

Used for superficial ulcerations and cutaneous eruptions. (Dr. Ches- 
ton.) 

R. — Acid, hydrocyanic, gtt. xx ; 
Cerat. simpl. §ij. M. ft. cerat. 

For papular eruptions attended with itching. (Dr. Sargent.) 

R. — Creasoti gtt. xx ; 
Cerati simpl. §ij ; 
Zinci oxidi 5j« M. ft. cerat. 

For seal j eruptions. (Dr. Sargent.) 

Ointments. — "These are fatty substances, softer than cerates, of 
a consistence like that of butter, and such that they may be readily 
applied to the skin by inunction." ( U. S. D) 

All of the officinal ointments, with the exceptions of the spermaceti 
and simple . ointments, are combined with more or less active and 
irritating medicaments. Before incorporating these with the fatty 
matter, they should be in the finest state of subdivision. 

These preparations, like cerates, by time and a high temperature 
are apt to undergo chemical change and become rancid ; and hence it 
is always better to prepare them in such quantities as immediate exi- 
gencies demand. It should be known, however, that this tendency to 
rancidity may be corrected to a considerable degree by the addition 
to the ointment of a small quantity of benzoin, poplar buds, or slip- 
pery-elm bark. To correct the fatty odor Dr. Geisler recommends 
ten drops of nitric ether to each ounce of the compound. 

The simple ointment as well as that containing spermaceti is 
emollient, and serves as a mild dressing for blistered surfaces, exco- 
riations from whatever causes, and wounds ; but their principal use 
is to form a basis for more active medicaments. Of these we may 
mention the unguentum antimonii, which acts as a very efficient sup- 
purative counter-irritant w r hen rubbed upon the skin ; this may be 
done twice a day or oftener, according to the effect produced. The 
skin should be unbroken, as the contact of the ointment with an 
excoriated surface sometimes produces an unpleasant degree of in- 
flammation, and, in rare cases, even gangrene. 

The strength of the ointment should vary according to the sensi- 
bility of the skin and the degree of effect desired: the officinal pre- 
paration contains two drachms of the tartar emetic to an ounce of 
lard, though the quantity may be increased to three drachms when a 
speedy action is necessary. The eruptive effects of this drug may also 
be obtained by sprinkling a strong solution of the powder upon adhe- 
sive plaster applied to the skin. 

The mezereon and elemi ointments are also irritant, and are used 
as stimulating applications to sustain the discharge from a blistered 
surface, issue, or seton, and in obstinate, ill-conditioned, and indolent 
ulcers. The ointment of Spanish flies is used for the same purpose. 



OINTMENTS. 65 

Creasote ointment "has been highly extolled as a dressing for skin 
diseases, and especially those of a scaly character. In chilblains it 
will often relieve the annoying sense of heat and itching like a charm. 

Among the astringent ointments are those of the acetate and car- 
bonate of lead, forming invaluable dressings in burns, inflamed blisters, 
and excoriated surfaces. 

The gall ointments, simple and compound, are now chiefly employed 
in cases of inflamed piles and prolapsus ani. 

The unguent of the subacetate of copper forms a mild escharotic 
in fungous granulations; and, diluted with lard, is a good stimulant 
to foul and flabby ulcers, scrofulous ulcerations of the edges of the 
eyelids, chronic otitis, to warts and corns, and to several forms of 
cutaneous eruptions. 

Mercurial ointment stands at the head of the alterative class of 
unguents, and is regarded as a good resolvent of indolent buboes, 
chronic glandular enlargements, and certain venereal nodosities of the 
bones and soft textures. 

To affect the economy to the extent of ptyalism, it is used by inunc- 
tion, about a drachm of the ointment being rubbed into the skin upon 
the inner aspect of the thighs, legs, or arms, morning and night, until 
the result is obtained. 

It has been highly extolled for preventing the pitting of the pus- 
tules of smallpox ; the ointment may be spread upon the inner surface 
of a mask made of leather or adhesive plaster. The ammoniated 
mercurial unguent is an excellent application to many skin diseases, 
as itch, herpes, and porrigo. Ointments containing the red oxide, the 
nitrate, the green, and red iodides of mercury, are also valuable pre- 
parations in dressing scrofulous ulcers, indolent sores from any cause, 
chronic ophthalmias, and various cuticular affections, and especially 
porrigo of the scalp. 

The application of the ointment of iodine with a camel's hair brush, 
morning and night, to the swollen tonsils after the disappearance of 
inflammation, will, it is stated, reduce them in two months. 

The combination of iodine and iodide of potassium is frequently 
employed in the form of an ointment to resolve goitrous and scrofu- 
lous tumors, and for the cure of certain varieties of obstinate skin dis- 
eases. 

The almost specific effects of those preparations containing sulphur 
in the cure of itch, crusta lactea, and tinea capitis are well known. 
Ointments of white hellebore, tobacco, tar, pitch, and the cocculus 
indicus, may be also had recourse to as a dressing for chronic cuta- 
neous eruptions with great advantage. 

The most frequently employed sedative ointments are those con- 
taining belladonna, conium, or stramonium, and are useful in many 
cases of irritable or painful ulcers, inflamed piles, and skin affections. 

In using any of the above compounds containing the salts of lead, 
the possibility of colica pictonum and paralysis occurring should be 
borne in mind. We should also carefully guard against producing 
the constitutional effects of the tobacco and the white hellebore enter- 
ing into the composition of some of the ointments. 
5 



QQ ON THE USE OF SOME TOPICAL REMEDIES. 

The following formulas will illustrate some of the usual forms of 
extemporaneous ointments, and at the same time furnish useful com- 
binations for the treatment of various surgical diseases : — 

R. — Zinci oxidi 5J I 
Adipis ^j. Misce. 

An astringent application in common use. 

R. — Morphise acetat. gr. vj ; 
Pulv. gallarum gj ; 
Unguent, stramonii ^j. M. ft. unguent. 

For hemorrhoids. (Harlan.) 

R. — Tincturse opii f5j ; 
Adipis ^ij. Misce. 

Used in painful and irritable sores. (Kicord.) 

R. — Plumbi iodidi 9ij ; 
Adipis ^j. Misce. 

This is very useful to stimulate an indolent or fungous venereal sore. 
(Eicord.) 

R. — Potassse carb. ,^ss ; 
Aquae rosse fgj ; 
Hydrarg. sulph. rubr. ^ ; 
01. bergam. 1'gss ; 
Fl. sulphuris, 
Adipis, aagix. M. ft. unguent. 

Aromatic sulphur ointment for itch. (Bateman.) 

R. — Hyd. subsulphat. 9ss; 

Unguent, cetacei §ss. M. ft. unguent. 

Ointment for skin affections. (Acton.) 

R.— Picis liquid. f|j ; 

Butyri salsi §ij ; 
Liquefac. una dein adde 

Potass, impur. ^j. 

Grafe's itch ointment. 

R. — Chlorid. hydrarg. corros. gr. j ; 
Camphorse pulv. $j ; 
Cerat. simp. Sjj. Misce. 

This is very useful to stimulate an indolent or fungous venereal sore. 
(Frestel.) 

R — Unguenti hydrarg. gij ; 

Extracti belladonnse ^iij. Misce. 

For the resolution of lymphatic engorgements. (Velpeau.) 

R. — Amrnonise muriatis £)iij ; 

Unguenti hydrarg. mitis giij. Misce. 

Use in scrofulous tumors, traumatic exostoses, and swellings of the 
bursas. (Dupuytren.) 

R. — Hydrarg. oxidi rubr. gr. v ; 
Cadmii sulphat. gr. iv ; 
Adipis |ss. Misce. 

Used in chronic ophthalmia and nebulous cornea. (Sichel.) 

R. — Extracti belladonnse 5*j 5 
Aquae f^ij ; 
Adipis §ij. Misce. 

Used to dilate the pupil, and the os uteri. (Chaussier.) 






PLASTEES. 67 

R — Unguenti hydrarg. fort. §j ; 
Antiuionii et potass, tart. 5J > 
Iodinii gr. x-xv. Misce. 

For chronic glandular tumors, old indurated buboes, &c. (H. John- 
son.) 

R. — Potassii cyanidi gr. ij ; 
Adipis §ss. Misce. 

An excellent application for pruritus vulvae, and to relieve the itch- 
ing of cutaneous eruptions. 

Plasteks.— " These are solid compounds intended for external 
application, adhesive at the temperature of the human body, and of 
such consistence as to render the aid of heat necessary in spreading 
them. Most of these have as their basis a compound of olive oil and 
litharge, constituting the emplastrum plumbi of the U. S. Pharmaco- 
poeia." (U.S.D.) 

In the preparation of plasters, care should be taken not to employ 
any degree of heat that would alter their composition, or drive off any 
volatile ingredient upon which their efficacy may depend. As the 
action of the air alters the color and consistence of plasters, they are 
usually found in the shops in cylindrical rolls carefully wrapped in 
paper. 

When freshly made, the plaster can be easily spread with a mode- 
rately heated spatula, and it remains soft, pliable, and adhesive. 

To use it as a dressing the material is thinly spread upon leather 
or linen ; the former being generally preferred when the application 
is to be made upon the sound skin, and the latter when upon exco- 
riated surfaces, or to bring the edges of a wound together. The fol- 
lowing is an excellent plan for obtaining a neat plaster. Take a piece 
of sheepskin, or some textile fabric of the proper size and shape, place 
upon its margins strips of adhesive plaster a half inch wide ; then, 
with a gently heated spatula, the roll of plaster is melted and evenly 
spread. When the strips are removed, a clean border will remain, 
which will prevent the patient's clothes being soiled, and at the same 
time enable the dresser to seize it at any point for removal. 

All plasters are more or less irritating, and when applied to the 
skin, they soften it, and prevent the insensible perspiration from 
escaping, thus keeping up a continuous local bath, to which, doubt- 
less, some of their good effects are attributable. In persons with very 
sensitive skins, the irritation they occasion is sometimes so annoying 
as to preclude their use; even inflammation and erysipelas have been 
occasionally observed to follow their employment. 

As gentle excitants in chronic articular diseases, scrofulous tumors, 
and indurations of the tissues from various causes, plasters of Burgun- 
dy pitch, of iron, of galbanum, and of ammoniac often serve a good 
purpose. 

That of ammoniac is sometimes combined with mercury, and re- 
sembles in its properties somewhat the emplastrum de Yigo cum mer- 
curio, so frequently employed by the French surgeons, and the formula 
of which is : Lead plaster two pounds eight ounces ; yellow wax two 
ounces; resin two ounces; bdellium, olibanum and myrrh, of each five 



68 ON THE USE OF SOME TOPICAL REMEDIES. 

drachms; saffron two drachms; mercury twelve ounces; turpentine two 
ounces ; liquid storax six ounces ; and oil of lavender two drachms. 
Melt the plaster, wax, and resin together, and add to the mixture the 
other materials. The plaster may be spread upon leather or linen. 

No dressing has been more highly praised than this as an applica- 
tion to the face, to prevent the pitting of the pustules of smallpox ; 
it is used in the same manner as mercurial ointment, smeared upon the 
inner surface of a mask. As a resolvent and stimulant in tumors and 
ulcers it has equally as much reputation. 

The emplastrum plumbi is a cooling and sedative dressing well 
adapted to the protection of excoriated surfaces and small wounds 
from the contact of the air, but it should be remembered that its con- 
tinuous use may produce lead colic. To obviate all danger from this 
source, it has been suggested to supply the place of the oxide of lead 
by the oxide of zinc, which, it is stated, has the further advantage of 
exercising a salutary local influence upon diseased surfaces by dimin- 
ishing the suppuration and facilitating cicatrization. 

A preparation composed of lead plaster and soap spread upon leather 
or sheep-skin is an admirable application to bed-sores, and for protect- 
ing the various bony prominences of the limbs from the pressure of 
splints. 

We have already spoken of the emplastrum resinse, or adhesive 
plaster ; and, therefore, have nothing further to say upon the subject 
under this head. 

The following are formulas for extemporaneous plasters: — 

R. — Saponis ^ij ; 

Emplastri plumbi t^ss ; 
Amnion, mur. gj. 
Melt the soap and lead plaster together, and when nearly cold, add sal ammoniac 
in fine powder. 

This plaster stimulates the skin, excites the action of the absorbents, 
and disperses many chronic swellings and indurations. (S. Cooper.) 

R. — Grummi ammon. §iij ; 
Extracti conii 5u 5 
Liq. plumb, acet. f^j. 
Dissolve the ammoniac in a little vinegar of squills, then add the other ingredients, 
and boil them all slowly to the consistence of a plaster. 

Discutient. (S. Cooper.) 

R. — Cerse flav. gxiij ; 
Terebinthinae 5hj ; 
Cupri subacetatis 9ij. 
Melt the yellow wax and turpentine together, and then add the salt of copper in a 
fine state of subdivision. 

Used to remove corns. (Kennedy.) 

R. — Extracti belladonna? £x ; 
Resinse elemi 5U SS j 
Cerse alb. 5.1 ss - 
Melt the resin and wax together, and add the extract. 

A good application in painful tumors. 

Instead of the belladonna, the extract of hyoscyamus, stramonium, 
or conium may be used ; the former of which with the addition of 



LINIMENTS. 69 

fifteen grains of gum opium, was employed by Hufeland, applied to 
the temples, to combat insomnia. Kicord employed opium and co- 
nium in syphilitic pains of the bones and joints. 

R. — Euiplastri conii ^ijss ; 
Picis Burgund. 5iss ; 
Emplastri plumbi giss. Misce. 
Spread upon a piece of leather the size of a dollar piece, and sprinkle over its sur- 
face ten grains of tartar emetic. 

Used to stimulate indolent buboes. (Corsin.) 

Liniments " are preparations intended for external use, of such con- 
sistence as to render them conveniently applicable to the skin by gen- 
tle friction with the hand. They are usually thicker than water, but 
thinner than ointments, and are always liquid at the temperature of 
the body." (U.S.D.) 

They are commonly applied by means of friction with the hand or a 
piece of flannel, though it is sometimes preferable to smear them upon 
cotton or linen, and lay this upon the diseased or injured parts. 

Liniments are generally stimulating and counter-irritant, yet we 
possess in the linimentum simplex of the Pharmacopoeia an agreeable 
emollient application in roughened and chapped conditions of the 
skin, and in the linimentum opii an anodyne useful in sprains and 
bruises and in rheumatic and gouty pains ; for the same diseases, the 
common domestic remedy is the ordinary hartshorn liniment. 

In recent burns and scalds an elegant and efficient dressing will be 
found in the linimentum calcis, smeared over raw cotton and then 
applied to the surface ; this is also called Carron oil, from having been 
used extensively at the Carron iron works in Scotland. 

The camphorated soap liniment, or opodeldoc, is an excellent article 
for cleansing and hardening parts subject to pressure, and is exceed- 
ingly refreshing to the feelings of patients confined upon their backs 
with fractured lower limbs. In these cases the liniment may be rubbed 
upon the skin of the posterior surface of the body with a fine sponge, 
and then wiped off with a soft towel. 

The compound ammoniacal liniment is directed, in the Pharmaco- 
poeia, to be prepared of two strengths, the first containing f of its bulk 
of strong liquor of ammonia, and the second of only t 5 q ; they are imi- 
tations of Granville's counter-irritant lotion, and are equally efficient. 

The stronger preparation is used where a speedy counter-irritant 
effect is desired ; it will produce rubefaction in from two to eight 
minutes, and vesication in from three to ten, and a caustic effect in a 
somewhat longer period. A convenient method of applying and lim- 
iting its action is to saturate a piece of lint with the strong solution, 
then place the lint in the lid of a pill-box, and lay this on the spot we 
desire to vesicate. 

Other forms of liniments are also occasionally used : the linimentum 
aeruginis, for repressing exuberant granulations and to stimulate flabby 
and ill-conditioned ulcers; the camphor, cantharidal, and turpentine 
liniments, to relieve rheumatic and neuralgic pains. Dr. Kentish origi- 
nally proposed the turpentine liniment as a remedy in burns and scalds. 
It should be applied as soon after the occurrence of the accident as 



70 ON THE USE OF SOME TOPICAL REMEDIES. 

possible, and should be discontinued when the peculiar inflammation 
excited by the fire is removed. It may be used in the same manner 
as the Carron oil. 

Formulae for extemporaneous liniments : — 

R. — Camphorse |iss ; 
Chloroform i fgij ; 
Olei olivse 13 ij. Misce. 

Used in neuralgic pains. (Price.) 

R.— Olei olivse fgij ; 
Balsam. Peru 5j > 
Spermaceti 5U 5 
Cerse alb. gij ; 
Acidi hydrochlo. fgij ; 
Aquae fgvj. Misce. 

An excellent stimulant in chilblains. (Hospital of Saint Antoine.) 

R. — Ammonia carb. gij ; 
Alcohol f^ij ; 
Aquae f^x. 
Dissolve the carbonate of ammonia in water, and add the alcohol. 

Useful in ecchymosis and contusions. (Swediaur.) 

R.— 01. tiglii f5ss ; 

01. cinnamomi f5j ; 

01. olivse f§j ; 

Lin. cantharid. fjj. M. ft. liniment. 

For neuralgia. (Prof. Jackson.) 

R. — Tinct. opii f^ij ; 
Saponis ^ss ; 
01. olivse Jiv. Misce. 

This is employed at the Hotel Dieu for its anodyne effects. 

R.— 01. terebinth., 
01. lini, aa Oss ; 
01. succini, 
01. juniperi, aa f§iv ; 
Petrol. Barbadensis ^iij ; 
Petrol. American. |j. Misce. " The British Oil." 

Used as a stimulating liniment. 

R. — Carbonis sulphu. f5j ; 
Camphorse gij ; 
Spts. vin. gal. f§ij ; 
01. olivse f§iij. Misce. 

Used in chronic articular diseases. (Wutzer.) 

R. — Extracti belladonnse gr. xv ; 
Tinct. opii gj ; 
01. olivse §j. Misce. 

To be gently rubbed upon the temples for insomnia. (Simon.) 

Glycekine.— When pure, glycerine is a thick, syrupy fluid, unctu- 
ous to the touch, without odor, colorless, or with a slight tinge of 
yellow, and having a very sweet taste. It is soluble in water and 
alcohol in all proportions, but insoluble in ether ; is insusceptible of 
rancidity, and does not undergo spontaneous change of composition 



GLYCERINE. 71 

by keeping or exposure. Scheele discovered it in 1789, and Mr. T. 
De la Rue, of London, first employed it surgically in 1846. 

It is produced extensively as a collateral educt in the manufacture 
of candies. According to the formula of the U. S. Pharmacopoeia, 
it is obtained for pharmaceutical use in the process for making lead 
plaster ; though the purest article is now prepared by subjecting fatty 
bodies to the action of water, at a high temperature under pressure. 

Its properties will vary according to the process employed in its 
manufacture ; when free from all impurities it is a very bland and 
soothing application ; while on the other hand, the presence of lime, 
chloride of calcium, sulphuric or hydrochloric acids, the most com- 
mon foreign matters present in it, will confer a more or less irritating 
quality. 

Glycerine has been used internally as an alterative and nutrient in 
those cases in which cod-liver oil is administered. 

As a dressing for wounds and ulcers, it possesses all the advantages 
of simple cerate, protecting their surfaces, and preventing the pieces 
of the dressing adhering to them, with the additional recommendation 
of keeping them clean and moist. We speak now of pure glycerine, 
for the admixture of the impurities above mentioned will render it 
unfit for direct application to recent solutions of continuity. 

The granulations, under the dressing, become florid, firm, and 
healthy, suppuration gradually diminishes, and cicatrization is pro- 
moted. 

The glycerine can be conveniently applied as follows : Moisten a 
perforated compress with it, which is to be placed upon the wound ; 
over this lay a gateau of charpie dampened with water ; then secure 
the whole with a few turns of a roller. The next day the dressing 
may be removed with ease, and the part cleansed, if necessary, with 
water and sponge. 

M. Maisonneuve employs, as a dressing for wounds, compresses 
saturated with glycerine either pure or holding in solution one-thou- 
sandth part by weight of carbolic acid. He believes the glycerolate 
of phenole formed in the above mixture a better disinfectant than the 
permanganate of potassa. 

Mixed with the materials of a poultice, in the proportion of from 
one to three drachms or more, it keeps the dressing moist and soft a 
long time. 

As an excipient it is also a useful article, freely dissolving iodine, 
iodide of potassium, morphia, strychnia, veratria, atropia, and tannin. 

Glycerine is used to relieve the dryness, occasioned by inflamma- 
tion of the lining membranes of the eyelids and external auditory 
canal, and to soften concreted cerumen ; as an emollient in pityriasis, 
lepra, herpes, and other skin diseases ; and, combined with borax, as 
an application to inflamed and ulcerated conditions of the throat and 
pharynx. 

The following recipes show the manner in which it may be com- 
bined with other drugs. 



72 ON THE USE OF SOME TOPICAL EEMEDIES. 

R. — Gunmii tragacanth. gr. xv ; 
Aquae calcis f§iv ; 
Glycerinae pur. f§vij ; 
Aqua rosae i'Jiij. Misce. 

Used in superficial burns, excoriations, impetigo, and chapped lips. 
(Stratin.) 

R. — Acidi nit. dil. fj;ss ; 

Bismuth, subnitratis ^ss ; 
Tiuct. digitalis f^ss ; 
Glycerinae pur. f3vij ; 
Aquae rosse f§iv. M. 

Used as a lotion in prurigo, lichen, lepra, and itching of the skin. 

R. — Sodae biboratis 5 SS_ 3J \ 
Glycerinae f5 v ij ; 
Aquae rosarum f^iv. Misce. 

Used for sore nipples, chapped lips, irritation of the skin from 
shaving, sunburn, and pityriasis. 

R. — Linimenti saponis camph. f^ij ; 
Glycerinae f5vij ; 
Extracti belladonnae 5j« Misce. 

A good application for sprains, contusions, and gouty, rheumatic, 
and neuralgic pains. (Bouchardat.) 

Lotions. — These are variously medicated fluids applied warm or 
cold to diseased parts according to the necessities of each individual 
case; they are always extemporaneous preparations, and hence are 
exceedingly numerous. Their therapeutical effects are usually astrin- 
gent, stimulant, narcotic, or refrigerant ; and the formulae below are 
examples of these different classes. 

Astringent lotions : — 

R.— Tannin 9j ; 

Spts. vini rect. f^ss; 
Mist, campli. f^vj. Misce. 

Used for spongy gums. 

R. — Aluminis 5lj 5 

Aquae rosarum f^viij. Misce. 

An injection in gonorrhoea, conjunctivitis, &c. 

R. — Gall arum cont. 5U ; 
Aquae pur. f^viij. 
Macerate five hours, and strain. 

The liquid may be employed in relaxed conditions of the mucous 
membranes of the throat, vagina, and rectum. 

R. — Zinci sulph. 5j ; 

Aquae pur. i'§viij. Misce. "The White Wash." 

Employed as an astringent in various forms of inflammation. 

R. — Liquor plumbi subacetat., 
Spts. vini, aa f 3J ; 
Aqua rosarum Oj. Misce. 

Used in chronic inflammations. 

R. — Cupri sulphat. ^ij ; 
Pulv. cinchonae £ss ; 
Aquae fluvialis f^viij. Misce. 

Used in syphilitic ulcerations of the throat. (Physick.) 



LOTIOXS. 73 

R. — Ferri et potass, tart. 5J > 
Aquae §j. Misce. 

An excellent lotion for sloughing sores. 

Stimulating lotions : — 

R. — Hydrarg. chlo. mitis 3J ; 

Aquae calcis f§viij. Misce. " The Black Wash." 
R. — Hydrarg. chlo. corros. gr. ij ; 

Aquas calcis f 3 viij. Misce. "The Yellow Wash." 

Both of these lotions are much used as a dressing for chancres, 
applied with a pellet of lint. 

R. — Acidi chlorohydric. gtt. xv ; 
Lactucarii ^ss ; 
Aquae pur33 f §vj. Misce. 

Employed as a mouth-wash in excessive ptyalism. (Ricord.) 

R. — Ammonias mur. ^ss ; 
Aceti, 
Spts. vini, aa, Oj. Misce. 

As a lotion in sprains, bruises, and ecchymoses. 

R. — Ammonias mur. 5j ; 

Spts. rosmarini Oj. Misce. 

Used as a discutient, and in the first stage of " milk breast." 
(Justamond.) 

R. — Sodas hiboratis 5j I 
Aquas pur. f §iijss ; 
Spts. vini f^ss. Misce. 

For sore nipples. (Sir A. Cooper.) 

R. — Liquor plumb, subacet. f§j ; 
Tinct. camph., 
Spts. vini, aa f^ss. Misce. 

As a discutient of tumors of the breast. (Brodie.) 
Narcotic lotions: — 

R. — Pulv. opii, ext. conii, est. belladon., vel ext. hyoscyami 
9j ad 5ij ; 
Aquas ferventis f §vj. 
Macerate two hours, and strain. 

Used as a dressing for painful ulcerations. 

R. — Acidi hydrocyan. f 3J ; 
Lactucarii £j ; 
Aquas f |iv. Misce. 

To relieve the pain of cancerous ulceration. (Magendie.) 

R. — Plumbi acet. ^ij ; 
Tinct. opii f§ss ; 
Aquas Oj. Misce. 

Used as a lotion to sprains, dislocations, &c. 

R. — Vini rubr. f§ij ; 
Tinct. opii f 3J ; 
Aquas f |ij. Misce. 

Apply to chancres with a pellet of lint. (Ricord.) 

Refrigerant lotions: — 

R. — Sodii chloridi, 
Potass, nitratis, 
Ammonias mur., aa §j ; 
Aquas Oij. Misce. 



<4 ON THE USE OP SOME TOPICAL REMEDIES. 

R. — Ammoniae mar. 5.1 > 

Potass, nitratis 5ij ; 

Aceti f |j ; 

Aquae f §x. Misce. Schmucker's Mixture. 
R. — iEtheris sulphuric, 

Alcohol, 

Liquor plumbi, aa f ^j. Misce. (Sargent.) 

Coll yet A. — In its most extended meaning, a colly rium signifies 
any remedy applied to the eye, whatever may be its physical con- 
dition, though the term is now generally used as a synonym of an 
eye-wash. 

Collyria are always extemporaneous formula, and are generally 
composed of astringent, stimulating, or narcotic drugs, combined in 
various proportions; the mild solutions being properly eye-washes, 
while the more active receive the name of eye-drops. 

They act either directly upon the parts to which they are applied, 
or by absorption. In the former case their action is generally con- 
fined to the skin and mucous membrane of the eye and its appendages, 
though it must be remarked that strongly irritating articles produce 
congestion of its deeper structures. Properly managed, they are ex- 
ceedingly neat and advantageous therapeutical means ; while, on the 
other hand, their careless or improper management may entail irre- 
parable damage, if not total loss, of the organ of vision. 

In applying an eye-wash, the liquid may be placed in a dish, and 
soaked up with a soft linen rag or sponge, and the eye washed with 
it, while the head is held over the vessel. When the secretion is very 
copious, a syringe charged with the fluid, and its beak gently insinu- 
ated beneath the lids, without pressing the ball of the eye, will effect- 
ually clear it away. 

Eye-drops are to be instilled into the eye by means of a quill, glass- 
tube, or camel's hair brush. Another way is to seat the patient in a 
chair with his head thrown back ; the diseased eye being closed, place 
a few drops of the solution in its inner corner ; then move the lids in 
opposite directions a few times until the collyrium has come in contact 
with every part of the conjunctiva. With a little elastic bottle and 
tube, the quantity may be graduated to a nicety. 

Eye-salves should be formed of finely-levigated powders, free from 
all grittiness, combined with such fatty matters as will readily melt by 
the heat of the eye. 

The most convenient way of applying them is to take a bit of the 
salve the size of a pin's head upon the end of a probe, and, raising the 
upper lid, place it beneath, and gently rub the lid upon the globe of 
the eye for a moment or so, while the salve is melting, to diffuse it 
over the conjunctiva. 

The eyelids may also be everted and the preparation applied with 
the point of the finger or a camel's hair brush. It is proper to remark 
that in all cases it will be better to remove all scales or scabs ad- 
hering to the margins of the lids by the preliminary application of 
glycerine. 

Eye powders should be very fine and impalpable; they usually 
consist of some metallic oxide in combination with powdered rock- 



COLLYKIA. 75. 

candy as a basis. The powder may be brought into contact with the 
conjunctiva either by taking it up upon the point of a camel's hair 
brush, or by placing it in a quill, and with a gentle puff of the breath 
projecting it into the eye. 

M. Gariel has invented an ingenious little instrument which he calls 
a pyxis, for this purpose. It consists of a hollow stem connected with 
a little gutta-percha bulb, which has its distal hemisphere enfolding 
with the proximal one in such a manner as to form a little cup-shaped 
cavity, into which the powder is placed. This is held opposite the 
eye, and the surgeon, placing the open end of the tube in his mouth, 
by a gentle puff forces outward the enfolded part of the bulb con- 
taining the powder, the latter impinging upon the conjunctiva. In- 
stead of the mouth, he sometimes uses a gum-elastic ball to effect the 
insufflation. 

These powders are objectionable on account of the pain they 
produce. All the good results likely to follow their application can 
generally be obtained by their solutions, yet in cases of obstinate 
ophthalmias, and corneal opacities, their use is still recommended by 
high authority. 

Eye-vapors have almost fallen into disuse; they are stimulating, 
narcotic, or emollient, according: to the nature of the substance from 
which they are obtained. The application is sufficiently simple — the 
patient has only to hold the diseased eye over the vessel from which 
the vapor issues. 

TThen there is ulceration of the cornea, care should be taken in 
using collyria containing opium and the salts of lead and silver in solu- 
tion; for by double decomposition of those bodies, there results a 
soluble salt of morphia, formed by the acid of the metal, and an 
insoluble meconate of the lead or silver, whichever is present, that 
fixes itself upon the ulcers, and forms permanent opacities. 

Strong collyria of any sort, when continued for a long time, produce 
chemical change and discoloration of the conjunctiva. 

The salts of mercury, copper, zinc, and cadmium will produce no 
deposition with opium. The application of eye-washes may be made 
by the patient or his attendants, but the other forms of collyria should 
be applied by the practitioner himself. 

For the purpose of expanding and contracting the iris, two active 
articles of the materia medica are used — belladonna and the Calabar 
bean. 

To produce an enlargement of the pupil, the belladonna in the 
form of an extract thinned a little with water, an ointment, or a solu- 
tion, is applied to the margins of the orbit pretty freely ; the result 
will be obtained, if the article is good, in four or five hours. To effect 
the same purpose more quickly and elegantly, the active principle of 
belladonna (atropia), dissolved in water (gr. ij-iv ad f.ij), is now 
more commonly employed ; two or three drops of this placed in the 
eye will dilate the iris fully in from two to twenty minutes. Other 
forms, recently introduced, are atropized paper and gelatine, which are 
prepared by incorporating the atropia with sheets of the two above- 
mentioned articles,. and then dividing them into little square pieces, 



76 ON THE USE OF SOME TOPICAL REMEDIES. 

each containing about -g\ of a grain of atropia. One of these squares 
is to be placed beneath the lid. 

For contracting the iris the Calabar bean is used, prepared with 
thin paper or gelatine, like atropia. 

The following are examples of some of the more common collyria: — 

]£. — Belladonnae extracti £ss ; 
Aquae purse fgviij. 
Solve et per linteurn cola. 
Sedative eye- water to be used tepid. (Jones.) 
]£. — Hydrarg. cyanidi gr. j ; 

Aquae destillat. fjiv. Misce. 

Used in glandular blepharitis of scrofulous patients. (Desmarres.) 

ty. — Extracti belladonnas gr. xx-xxx ; 
Aquae destillatae f§j. 
Solve et per linteurn cola. 
To be dropped into the eye for dilating the pupil. 
!£.. — Atropiae sulphat. gr. ij-iv ; 
Aquae destillatae f§j. Ft. sol. 

For the same purpose as the preceding. 

]£. — Tannin gr. xx ; 

Aquae pur. §j. Solve. 
To be dropped into the eye. 

]£. — Cupri sulph. gr. j ; 
Tinct. opii gtt. x ; 
Aquae destillat. f§ss. Solve. 
Drop into the eye. 

For chronic ophthalmia. (Sichel.) 

I£. — Zinci sulph. gr. x ; 

Sodii hydrochlor. gr. x ; 

Aquae rosarum f§j. Misce. 
To be dropped into the eye. 

R^. — Zinci sulph., 

Sodii hydrochlor. , aa, £j ; 

Aquae rosarum f^viij. Solve. 

An eye-wash. (Hartshorne.) 

ty.. — Lapidis divini gr. xv ; 

Aquae rosarum f§ij. Solve. 
To be dropped into the eye for chronic conjunctivitis. (Bouchardat.) 

The same quantity to eight ounces of rose-water will make a good 
eye-wash. 

I£. — Argenti nitratis gr. v-x ; 

Aquas purae f5j. Solve. 
To be used as eye-drops in inflammatory conditions of the conjunctiva. 
ty. — Hydrarg. bichlor. gr. j ; 

Ammonias hydrochlorat. gr. x ; 

Aquae rosarum f§viij. Solve. 

An eye-wash. 

R. — Cadmii sulph. gr. j ; 
Tinct. opii gtt. x ; 
Aquas destillat. fjss. Solve. 

Eye-drop. (Sichel.) 



GARGLES. 77 

I£. — Praecipitati alb. gr. xv ; 

Tutiae praep., 

Boli armen. ppt., aa 5ss. 

Adipis suilli ^j-^ij. 
M. exactissime, ft. unguent, ophthal. 

James' ointment. 

I£. — Hyd. oxidi flav. gr. x-lx. 
Ung. cetacei §j. M. 

An admirable application in conjunctivitis and phlyctenular cor- 
neitis. (Pagenstecher.) 

]£. — Argenti nitratis gr. x ; 

Aquae destillat. q. s. ad solveud. nitrat. ; 
Unguenti cetacei §j. 
Prius solvatum uitras ; dein misceatur accuratissime solutio cum unguento. 

Used in chronic and acute inflammations of the conjunctiva. (Jones.) 

R.. — Oxidi hydrarg. rubri bene levigat. gr. iij-vj-xv ; 

Axungiae praeparat. ^ij. Misce accuratissime ft. unguent, opli. 

For inflammation of the eyelids, and ulcers and specks of the cornea. 
(Jones.) 

R,. — Acidi tannic, 

Pulv. sacch. alb., aa pp. a?q. Misce et tere ut ft. pulv. subt. 
R,. — Plumbi acetatis gr. x ; 

Saccliari alb. gj. Misce et tere, etc. 
R,. — Calomelanos, 

Sacchari purif., aa pp. aeq. Misce tere, etc. 
J$.. — Oxidi hydrarg. rubri gr. x ; 

Sacchari purif. gj. Misce et tere, etc. (Jones.) 

These ophthalmic powders are to be applied to the eye in the man- 
ner above directed. 

Gargles. — These are liquid medicated preparations destined to act 
upon the mucous membrane of the mouth and pharynx. Their action 
is exclusively local, as they remain so short a time in contact with 
the parts that no absorption can take place, and therefore no remote 
effects can follow. 

The quantity directed for a gargle may be six or eight ounces, 
which will suffice to wash out the throat five or six times during the 
day. 

In the act of gargling, almost all the muscles of the neck, larynx, 
and pharynx participate, and it will, therefore, be prudent to abstain 
from the use of these preparations in severe inflammatory conditions 
of the throat, as it is probable that more pain will be inflicted and 
more injury done in such cases than can be counterbalanced by the 
advantage derived from their use. Yet even in these instances the 
gargle may be available; by simply taking i,t in the mouth, and 
throwing the head back, the fluid will be carried by its own gravity 
over the diseased surface, where it may be permitted to remain a few 
moments. 

As the act of gargling is accomplished by the voluntary and forci- 
ble emission of the breath through the liquid, the agitation of which 
gives rise to the peculiar sound from which the name is derived, this 
mode of medication is impossible in very young children. 



78 ON THE USE OF SOME TOPICAL EEMEDIES. 

Strong solutions and the powders of certain drugs may be conve- 
niently applied to the throat with a camel's hair brush mounted upon 
a long handle, or a bent probang, or even the index finger : in this 
manner Bretonneau has availed himself of the action of powdered 
alum, calomel, and other medicaments in the treatment of croup and 
inflammatory affections of the throat. The therapeutical effects of 
gargles are generally emollient, astringent, tonic, or detersive. They 
are the objects of extemporaneous prescription of which the following 
recipes are characteristic examples : — 

I£. — Acidi chlorohyd. f5ij ; 
Mellis fgj ; 
Decoct, hordei Oj. Misce. 

Used in aphthous ulcerations of the mucous membrane, gangrenose 
angina, and ptyalism. (Eicord.) 

I£. — Ammoniae hydrochlo. 5J ; 

Mellis giss ; 

Aceti gij ; 

Aquae rosarum §xij. Misce. 

A good detersive and stimulating gargle in congestive conditions 
of the mucous membrane. 

I£. — Aluminis gj ; 
Mellis f§j ; 
Aquae rosarum f^viij. Misce. 

An astringent gargle. 

I£. — Sodae biboratis ^ij ; 

Syrupi gumrni acac. f§j ; 
Decoct, hordei Ojss. Misce. 

Employed in aphtha. 

I£. — Hydrarg. bichlo. gr. ij ; 
Mellis ffss; 
Aquae destillat. 13 iv. Misce. 

For syphilitic ulceration of the throat. 

I£. — 01. terebinthinae fgss ; 

Mucilag. gummi arab. f^iv. Misce. 

Used to control excessive salivation. (Geddings.) 

I£. — Potass, chloratis 5*j J . 

Mellis f§ss ; 
Aquae purae fjiv. Misce. 

For the same purpose as the above. 

]£. — Acidi sulphurici gtt. xx ; 
Mellis gj ; 
Decoct, hordei fgiv. Misce. 

A detersive gargle in gangrenous inflammations of the throat. 

ty. — Sinapis alb. gss ; 
Sodii chlo. 5iss ; 
Aceti fjss ; 
Aquae ferventis fjviij. Misce. 

Used in inflammatory affections of the throat. (Fleury.) 

Collutories are certain forms of remedial agents intended for appli- 
cation to the mucous membrane of the mouth. Powdered alum, calo- 
mel, and borax are occasionally applied with a camel's hair brush to 
the ulcerations occurring in the same parts. 



POULTICES. 79 

The following are illustrative forms in which collutories are or- 
dered : — 

R. — Cincho. rnbr. pulv., 
Carbo. ligni pulv., 
Irid. flor. pulv., aa 3ij. Misce. (Dunglisou.) 

I£. — Tinct. myrrh, f^ss ; 

Tinct. ciucho. f^j. Misce. 

These formulae are used in cases of sponginess or excrescences of 
the gums. 

1$.. — Calcis chlorinat. gr. xx; 
Mucilag. acacia? f 5 j ; 
Syrupi fjss. Misce. 

For mercurial sore mouth. 

I£. — Sodse biboratis 3j ; 
Mellis t'5J. Misce. 

Used for aphthous ulcerations. 

Poultices, or Cataplasms, are soft, moist, and pap-like substances, 
for spreading upon muslin, and intended for external application. 

When they act by virtue of their warmth and moisture only, they 
are called simple poultices, while the addition of any drug confers 
the name of medicated or compound poultices upon them. 

Their base, or excipient as it is called, is usually some farinaceous 
substance, such as linseed meal, rice, barley, or wheat flour, crumb 
of bread, sometimes the roots, bulbs, and leaves of certain plants, 
such as the potato, the carrot, onion, marshmallow, and benne. 

The vehicle of a simple poultice may be water or any other bland 
fluid, and this charged with active principles before being mixed 
with the excipient furnishes cataplasms with qualities as varied as 
the principles themselves. 

Various animal matters have been employed in this manner, and it 
need scarcely be remarked that they are as inefficient as they are dis- 
gusting. In this category fall those poultices made of the common 
earth-worms, snails, and the various parts of freshly-killed animals. 
A chicken or other fowl split in halves, that the warm, steaming flesh 
and blood may come in contact with the diseased parts, is sometimes 
used as a popular remedy for the poisonous bites of certain animals, 
as snakes and mad dogs. 

In the preparation of a poultice we cannot do better than follow 
the advice of Mr. Abernethy, who studied with great care and en- 
thusiasm this form of surgical dressing. For making a bread poultice 
he says : " Put half a pint of hot water into a pint basin ; add to this 
as much of the crumb of bread as the water will cover; then place a 
plate over the basin, and let it remain about ten minutes ; stir the 
bread about in the water, or, if necessary, chop it a little with the 
edge of the knife, and drain off the water by holding the knife on the 
top of the basin, but do not press the bread, as is usually done ; then 
take it out lightly, and spread it about one-third of an inch thick on 
some soft linen and lay it upon the part." "When thus made," he 
rapturously exclaims, "Oh! it is beautifully smooth; it is delightfully 
soft : it is warm and comfortable to the feelings of the patient." 

For a linseed-meal poultice he directs you to " scald your basin by 



80 ON THE USE OF SOME TOPICAL REMEDIES. 

pouring a little hot water into it, then put a small quantity of finely- 
ground linseed meal into the basin, pour a little hot water on it, and 
stir it round briskly until you have well incorporated them; add a 
little more meal and a little more water, then stir it again. Do not 
let any lumps remain in the basin, but stir the poultice well, and do 
not be sparing of your trouble. If properly made, it is so well worked 
together that you might throw it up to the ceiling, and it would come 
down again without falling to pieces ; it is, in fact, like a pancake. 
What you do next, is to take as much of it out of the basin as you 
may require, lay it on a piece of soft linen, let it be about a quarter 
of an inch thick, and so wide that it may cover the whole of the 
inflamed part." 

If any of the constituents of poultices are volatile, the degree of heat 
to which they are exposed in preparation should be carefully watched, 
that their chemical integrity may not suffer change. 

A temperature between 80° and 90° Fahr. will be both safe and 
appropriate for an emollient poultice; at a few degrees above this ex- 
citant and even rubefacient effects follow. 

It will add much to their elegance and efficiency first to make a 
solution in water of any remedial agent we may desire to use, and 
then incorporate it with the other materials ; thus, instead of employ- 
ing bruised, or chopped vegetable matters, we use their decoctions or 
infusions where it is practicable. 

Cataplasms may be applied directly to the skin, or have interposed 
a piece of gauze, tulle, or fine open textured muslin. The first plan 
is generally preferable, as the pasty consistence of the poultice permits 
an accurate contact with the whole extent of any surface however 
irregular, and it ought to be especially adopted when there is present 
any principle intended for absorption. The interposition of a piece 
of cloth has the supposed advantage of preventing any part of the 
poultice sticking to the skin, or flowing beyond the limits intended 
and soiling the clothes of the patient's bed. But when the cataplasm 
is properly made, these objections do not exist, and, therefore, the 
interposed muslin is useless, except, perhaps, when the applications 
are destined for the eye, ear, and nostrils. 

It should also be observed that an uncovered poultice is more 
agreeable to the feelings of a patient than one provided with a cover- 
ing of tulle or other material. The warmth and moisture of a poul- 
tice may be, to some extent, sustained by covering it with a sheet of 
oil silk, or India-rubber. 

To retain the dressing in its proper position, we use the many-tailed 
(Fig. 58), or roller bandage, or that of Scultetus. In the former case 
the limb covered with the poultice is placed upon the centre of the 
bandage spread out upon the bed, or a pillow ; then commencing 
below, the strips are crossed from side to side alternately. Each of 
them ought to overlap a third or half its predecessor, and be suffi- 
ciently long to encircle the limb once and a half. 

When a strip becomes soiled it may be removed and another sub- 
stituted for it without disturbing the rest of the bandage. 

A small cataplasm may be conveniently retained, by crossing over 



POULTICES, 



81 




it narrow strips of adhesive plaster, suffi- Fi g- 58 « 

ciently long to extend two or three inches 
beyond its margins. 

The removal of a poultice is neatly 
accomplished by seizing it by one of its 
margins and gradually reflecting it upon 
itself until it is entirely detached from the 
skin. Any of the paste adhering to the 
surface may be dislodged by allowing warm 
water to trickle upon it, and then be scraped 
off with the spatula. Should it be too hard 
to be removed in this way, the application 
for a few minutes of a compress wrung 
out of warm water will soften it sufficiently 
to admit its separation. 

Before renewing the poultice, the surface 
should be carefully cleansed and wiped with 
a soft towel. 

Cataplasms by their warmth and humidity 
maintain a constant warm bath around the 
parts with which they are in contact ; they 
soften the skin and facilitate the absorption 
of any medicament which may be incor- 
porated with them. In order to obtain 
uniform effects, an unvarying temperature 
must be kept up by changing the poultice 
every two or three hours, or even more fre- 
quently if necessary. Left on too long, its moisture escapes, leaving 
behind a dry, hard, and irritating mass, the albuminoid constituents of 
which undergoing chemical changes produce a dough at once uncon- 
genial to the feelings of the patient and hurtful to the surface beneath. 
Medicated poultices should be changed yet more frequently than the 
simple, particularly where they contain elements alterable by heat. 

The long-continued use of cataplasms augments the sensibility 
of the tissues, rendering them tender, causes debility, and in the case 
of granulating wounds or suppurating buboes, they may induce such 
a degree of atonicity as to arrest, or materially interfere with the 
recuperative efforts of nature ; erysipelas and even gangrene have 
sometimes been seen to follow the same practice. 

A vesicular or pustular eruption, accompanied with excessive itch- 
ing, has been noted as an occasional occurrence, and demands the 
substitution of warm water-dressings for the poultice. A grayish 
colored puffiness also not unfrequently follows their persevering use 
upon suppurating surfaces. 

In some diseases of the skin, and in superficial erysipelas, warm 
poultices are sometimes exceedingly painful: in such cases water- 
dressings will answer better ; and, indeed, as a general rule they should 
always be chosen when a temperature below that of the skin is desired 
to be maintained in a part. 

1st. Emollient poultices. We have already adverted to the direc- 



Application of the many-tailed band- 
age for retaining cataplasms. 



82 ON THE USE OF SOME TOPICAL REMEDIES. 

tions given by that astute surgeon, Mr. Abernethy, for preparing the 
common bread crumb and flaxseed meal poultices. In the same 
manner we may employ other materials, such as bran, corn-meal, rice, 
wheat or barley flour, and the pulps of apples, carrots, or onions either 
raw or boiled. The vehicle may be water, milk, or other bland fluid. 

Emollient cataplasms were formerly much employed in the treat- 
ment of recent wounds ; but this practice is now nearly abandoned, 
the more elegant water- dressing usurping their place. Often in in- 
flamed ulcers great relief from suffering is experienced by the patient 
from the use of a linseed-meal poultice. 

But it is in cases of inflammations of the cellular tissues, or phleg- 
mon, that these remedies are most often had recourse to ; they favor 
maturation, and when the pus is discharged, tend to dissipate any 
remaining engorgement of the tissues. 

Deep-seated inflammation, as of an interior organ, may be benefi- 
cially influenced by a large warm poultice surrounding the chest or 
abdomen. For the same purpose a jacket, made of oil silk or India- 
rubber, and placed next to the skin, will also be found advantageous ; it 
confines the insensible perspiration, and thus acts in the manner of a 
poultice, besides protecting the skin from sudden changes of tempera- 
ture ; it is also lighter than a poultice. 

The caution should always be taken in the use of emollients to 
stop short of determining any hurtful relaxation of the skin and subja- 
cent cellular tissue, or enfeeblement of granulating wounds, or local 
capillary congestion, which will retard the plastic process and subse- 
quent cicatrization. We should, as a general rule, abstain from them 
as far as possible in passive dropsies, and in parts disposed to gangrene. 

2d. Stimulating cataplasms are such as contain some stimulating 
drug in their composition. It has already been observed that the 
most elegant method of making these is by the addition of an infusion 
or decoction of the medicament to the vehicle before it is mixed 
with the linseed meal or bread crumb, yet an efficient and gently 
excitant application can be obtained by using the powdered aromatic 
plants, such as sage, rosemary, mint, rue, tansy, and wormwood, in the 
proportion of one or two ounces of the powder to the materials of an 
ordinary sized cataplasm. Some practitioners simply soften these 
herbs in warm water, and inclose them between two pieces of muslin. 

Tansy and wormwood have been used as anthelmintics in the shape 
of poultices laid over the abdomen, and may be regarded as useful 
adjuvants to more active internal remedies. In cases where the latter 
could not be employed, these poultices would be of prime importance. 

The pulp of the horseradish root and the rhizoma of the Indian 
turnip form pretty active stimulating poultices, and the same remark 
applies to several of the indigenous species of the cruciferous and 
ranunculous plants which can be obtained in various parts of the 
country, and used instead of other more expensive, or, perhaps, un- 
attainable articles. 

The resins in tincture or powder may be added to emollient 
poultices, but they are now chiefly employed in the form of plasters. 

Chlorohydric, nitric, acetic, and oxalic acids are excellent local 



POULTICES. 83 

stimulants, the three former in the proportion of one to two drachms 
mixed with the materials of a common-sized cataplasm. Velpeau 
has derived advantage from the use of poultices containing slices of 
lemon, in hospital gangrene. 

Mustard cataplasms will be considered in the section on rubefacients. 

Alcohol, solutions of chlorinated soda, and the ammoniacal salts, 
aromatic tinctures, and that of camphor will form useful stimulating 
applications added to a poultice in quantities varying from one to 
four drachms. 

A poultice made with yeast, sour beer, or porter is a favorite remedy 
with some in the treatment of gangrene ; it favors the separation of the 
sloughs, and is a corrective of any accompanying fetor; the latter 
quality depending upon the antiseptic property of the carbonic acid 
developed during the fermentation of the poultice. 

The stimulating poultices are used to promote the absorption of 
the effused fluids, in contusions and sprains, to resolve chronic glandu- 
lar enlargements and other tumors ; to stimulate the granulations of 
flabby ulcers; and to arrest mortification, or when the tissues are 
dead or sphacelated to hasten their separation. 

Those containing alcohol and the volatile oils have an excitant 
action, and may be advantageously employed in the treatment of the 
chronic inflammations affecting old worn-out persons. 

3d. Astringent poultices are commonly made of powdered cinchona, 
tormentilla, bistort, gall-nuts, tan, or tannin. These powders may be 
mixed with the paste of a flaxseed, or bread-crumb poultice, or even 
employed alone, being previously converted into a plastic mass with 
water. 

The astringent metallic salts, such as the sulphates of copper, zinc 
and iron, alum, the acetate of lead and Goulard's solution, dissolved 
in water, answer a better purpose than the preceding articles, in cases 
where very powerful astringent and resolvent effects are desired. 

These poultices constringe the tissues actively, and will therefore 
be found useful in arresting passive hemorrhages and in giving tone 
to relaxed parts, and in phagedenic ulceration, and sloughing buboes. 

I have found a light poultice containing the sulphate of iron an 
admirable remedy in certain cases of erysipelas. 

It has been recommended to apply a poultice containing cinchona, or 
a solution of quinine, to the abdomen of children suffering with 
intermittent fevers, where these remedies cannot be borne by the 
stomach. 

4th. Narcotic cataplasms are obtained by mixing with the excipient 
a decoction of poppies, the watery extract of opium, or the extracts 
of conium and belladonna. The late Dr. Y. Mott recommended 
highly a poultice prepared by incorporating the fresh leaves of the 
stramonium plant with linseed meal, or bread previously softened in 
water. The leaves themselves sufficiently moistened may also be used. 
Velpeau, in retention of urine, sometimes had recourse to a poultice 
of pellitory applied over the hypogastrium. Mr. North applied 
moistened tobacco leaves to certain cases of local inflammation 
attended with spasms. 



84 ON THE USE OF SOME TOPICAL REMEDIES. 

Besides the above uses, narcotic poultices are employed in con- 
tusions, sprains, and in rheumatic and neuralgic pains, and colics. 

Mr. Markwick, of London, brought forward as a substitute for emol- 
lient poultices and fomentations a soft porous material called spongio- 
piline, prepared by felting together sponge and wool, and afterwards 
rendering one side of the sheet impervious by coating it with a layer 
of India rubber. It is an exceedingly elegant article, but too ex- 
pensive for general use, as separate pieces would be needed for each 
particular case. The fact should also be stated that spongio-piline is 
not near so agreeable to the feelings of a patient as a well-made 
poultice. The same piece can be used many times to an unbroken 
surface without any danger ; but in suppurating wounds, it absorbs the 
pus, from which it is very difficult to cleanse it. The best manner of 
doing so is to wash the spongio-piline carefully in warm water, and 
then in a solution of the chlorinated soda ; lastly, dry it, and pass a 
moderately hot flat-iron over its surface, taking care not to injure the 
texture of the material by the heat. Its mode of application is simple, 
a piece little larger than the surface to be covered is cut from the 
sheet, dipped in warm water, and applied with its unglazed side to 
the skin. 

The following formulas will show the method of preparing the 
different kinds of poultices : — 

R. — Pulv. lini :§vj ; 

Aquse ferventis Ibiss. Misce. 

The best emollient poultice. Any other farinaceous substance can 
be used instead of the linseed meal. 

R. — Rad. carotse recentis H5j. 
Bruise in a mortar, or, better, grate it to a pulp, and spread on muslin. 

" Carrot poultice is employed as an application to ulcerated cancers, 
scrofulous sores of an irritable character, and various inveterate ma- 
lignant ulcers." (S. Cooper.) 

R. — Farinse ibj ; 

Cerevisise fermenti, 
Aquse, aa f§v. 
Mix the yeast with the water, and add the flour, stirring so as to make a cataplasm. 
(U. S. Dispensatory.) 

R. — Pulv. carbonis 5"j 5 
Micse panis ^ij ; 
Pulv. lini 5 X 5 
Aquas bullientis f§x. 
" Macerate the bread with the water for a little while near the fire ; then mix, and 
gradually add the flaxseed, stirring so as to make -a soft cataplasm. With this mix 
two drachms of the charcoal, and sprinkle the rest upon the surface." (Pharm. Lond.) 

This is an excellent application to fetid and gangrenous ulcers, and 
should be frequently renewed. 

R. — Liquor sodse chlorinat. f§ij ; 
Pulv. lini %iv ; 
Aquse bullientis f^vj. 
" Add the flaxseed gradually to the water, constantly stirring ; then mix in the 
chlorinated soda." (Pharm. Lond.) 

Used to diminish scrofulous tumors and glands, and as a stimulating 
and antiseptic application to sloughing and other fetid ulcers. 



WATER IN SURGICAL DISEASES AND INJURIES. 85 

R.— Aceti fgj ; 

Cataplasniatis lini Ibj. Misee. 

Used in bruises and sprains. The mineral acids in the proportion 
of from one to two drachms may be added to a similar quantity of a 
flaxseed poultice. 

R. — Cataplasmatis aluminis q. s. 
" This is made by stirring the whites of two eggs with a bit of alum, till they are 
coagulated. In cases of chronic and purulent ophthalmia, it has been applied to the 
eye, between two bits of rag ; and it has been praised as a good application to chil- 
blains which are not broken." (S. Cooper.) 

R. — Ainmonise hydrochlor. gss ; 

Liquor plumbi, subacetatis f^j ; 
Cataplasmat. lini ^iv. Misce. (Ratier.) 

Employed as an application to local inflammations. 

R. — Extracti conii £j ; 
Pulv. lini §ivss ; 
Aquse bullientis f§x. 
11 To the water gradually add the flaxseed, constantly stirring, so as to make a cata- 
plasm. Upon this spread the extract previously softened with water." (Pharm. Lond.) 

Used in scrofulous, cancerous, syphilitic, and other painful ulcers. 

R. — Extracti opii aquosi f5J-f5u : . 
Cataplasmat. lini lb j . Misce. 

A narcotic poultice may also be obtained by simply sprinkling the 
surface of an ordinary poultice with the tincture of opium. 



CHAPTER IV. 

ON THE USE OF WATER IN SURGICAL DISEASES AND INJURIES. 

The employment of water in surgical practice is an important sub- 
ject, and demands a careful study both as regards its local as well as 
its general effects. 

Judiciously managed, the surgeon possesses in water an efficient 
remedy for the relief and cure of a very large class of diseases that 
habitually come within the sphere of his observation. It is at once 
simple and effective, always at hand, and, not an unimportant con- 
sideration, it costs nothing ; so that the indigent, and those cut off by 
accident or necessity from communities where all the conveniences 
for the care of the wounded and sick are present, have in water a 
precious remedial agent, and one far better, in a majority of cases, 
than the most elaborate surgical dressings. 

Bathing was had recourse to by the ancient Greeks and Romans 
both as a cure for disease and as a luxury; and the extent to which 
they indulged in it is shown by the ruins of those magnificent struc- 
tures designed by them for this purpose — one of them being described 
as containing six thousand separate baths. It is now used over the 
known world for this twofold object. 



86 WATER IN SURGICAL DISEASES AND INJURIES. 

We propose, "however, in this place to consider more particularly 
the use of water as a surgical dressing, and afterwards to devote a few- 
pages to the consideration of the manner of employing it in bathing. 

SECTION I. 

WATER AS A SURGICAL DRESSING. 

Water-dressings are either cold, warm, or medicated; and are 
adapted under various conditions of temperature and medicinal im- 
pregnation to the treatment of numerous surgical injuries. 

This method, as a uniform practice, is almost peculiar to modern 
surgery, our predecessors delighting in the profuse application of 
salves, plasters, and healing balms, and swathing sore and wounded 
parts in bundles of bandages, and various other dressings, to the cer- 
tain detriment of their patients. 

It should be observed, however, that Hippocrates and some of his 
successors did employ both hot and cold water in their practice, but 
unfortunately their example was not generally followed by surgeons, 
and it was not, indeed, before the sixteenth century that attention was 
again drawn to the subject. 

In 1553 the quack Doublet, during the siege of Metz, performed 
wonderful cures with clear water from the fountains and wells, and 
the celebrated Pare imitated his example. 

Still later, Percy, Larrey, Breschet, Berard, and Yelpeau, both wrote 
of and demonstrated by their practice the superiority of water over the 
old vulnerary applications. The latter surgeon states that he used it 
extensively with signal success in the treatment of certain fractures, 
phlegmonous erysipelas, burns, and in various wounds from contusing 
and cutting instruments ; after operations upon the eye, in amputation, 
and a great number of other operations. He remarks, in regard to 
its advantages and disadvantages : " If it is true that cold water-dress- 
ings employed in this manner during the hot season are excellent 
topical applications, it is also equally true that in cold weather it is 
much better to have recourse to tepid water ; so also is it true that 
the water, whether cold or tepid, almost always wets some region that 
we would have wished to protect; that it exposes to chills, colds, 
rheumatisms, inflammations of the chest, and a great number of affec- 
tions often more serious than the disease itself. It is also proper to 
say that applied indifferently to all kinds of wounds, it may produce 
as much evil on the one hand as good on the other. By retarding 
the circulation, it produces gangrene of the contused or divided 
tissues; and by deranging the phenomena of inflammation, it fre- 
quently vitiates the suppuration, and rarely admits of immediate 
adhesion of the lips ojp the wound." 

In England, Liston advocated very strongly the substitution of 
water-dressings for poultices, believing them to possess all their ad- 
vantages, with the additional recommendation of greater neatness and 
cleanliness, and not becoming sour or injuring the sound parts. 

Macartney considers that they act differently ; and says that a 
water-dressing, unlike a poultice, prevents or diminishes the secretion 



COLD WATER-DRESSINGS. 87 

of pus, checks the formation of exuberant granulations, and removes 
all pain. 

Kern, of Vienna, and Esmark, of Kiel, were the supporters and 
champions of the practice in Germany. 

American surgeons have generally adopted the use of water in the 
treatment of wounds, fractures, and local inflammations. 

In applying water care should be taken that it does not wet the 
patient's clothes, or the bed ; this can be easily accomplished by means 
of a sheet of India-rubber or oiled silk, placed beneath the part upon 
which the dressing is applied. 

Cold Water-dressings are most frequently employed in the treat- 
ment of superficial inflammations, fractures, gunshot wounds, and 
inflammatory engorgements. 

The action of the cold is to reduce the volume and temperature of 
the parts to which it is applied, to constringe the muscular fibres, 
both through the purely physical effect of condensation, and by vital 
contractility, and thereby diminishing the calibre of the blood- 
vessels and the volume of blood circulating through them as well as 
its rapidity. The chemical and vital forces constantly taking place 
in the living tissues are also retarded. 

The water should not be so cold as to produce shivering, or other 
disagreeable sensations, and the dressing should not consist of more 
than a simple fold of soft linen or lint, and it is also important to leave 
it exposed to the air that continual evaporation may take place, else 
the heat of the parts will soon raise the temperature of the cloths and 
thus defeat the objects in view, and instead of obtaining the thera- 
peutical effects of cold, we shall have those of a fomentation, which 
are quite different. 

When the linen is simply wrung out of water it will require fre- 
quent changing, in order to keep down the temperature. A piece of 
ice, of sufficient size to be easily borne by the part, may be placed 
upon the dressing, and its frequent removal will thereby be avoided. 
I prefer, however, an arrangement whereby a constant supply of cold 

Fig. 59. 




Apparatus for cold water-dressiDg. 



water can be obtained from a cup with a few small holes perforating 
its bottom, and lightly closed with a few filaments of charpie so that 



88 WATEE IN SURGICAL DISEASES AND INJURIES. 

the fluid issues in drops. A cotton wick with one end immersed in 
the water in the vessel and the other resting upon the muslin to be 
wetted will answer the same purpose, as is seen in Fig. 59. This simple 
plan can be pursued anywhere, and requires little surveillance. 

I have derived benefit from water-strapping in ulcers and certain 
forms of inveterate skin diseases, such as eczema of the lower ex- 
tremities. Strips of muslin or linen are taken and soaked in cold 
water until they are thoroughly saturated, and they are then applied 
in the same manner as Baynton's dressing already described. 

When a powerful and sudden impression of cold is sought for, as in. 
strangulated hernia, some surgeons apply a thin slice of sponge satu- 
rated with ether. 

M. Jobert, Surgeon to the Hopital St. Louis, Professor Miller, and 
Mr. Earle were strongly in favor of treating burns with iced water, 
by covering the burnt parts with pledgets of lint dipped in that fluid, 
or with bladders of ice, and continued not for minutes, but for hours. 
Of course, in extensive burns attended with depression, this method 
would be inapplicable from the sedative effects of the cold applied to 
so large an extent of surface. 

Warm Water-dressings, or fomentations, are much more easily 
managed than cold ; the temperature of the water should be such that 
the patient experiences agreeable sensations from its use. It may be 
applied by means of a piece of soft muslin folded, or, what is better, 
a piece of flannel. To prevent evaporation and consequent cooling, 
a piece of oiled silk large enough to more than cover the muslin may 
be laid over the dressing, and the whole secured, if necessary, with a 
few turns of a narrow roller. 

When the inflammation and the discharge of pus are moderate, the 
linen need not be disturbed more than three or four times a day, care 
being always taken to have a fresh piece of cloth ready the moment 
the previous one is removed, that no sudden changes of temperature 
may happen to the part. It will also be advantageous to abandon 
the use of the warm water-dressings gradually. 

Amussat, in order to do away, as much as possible, with these 
sudden alterations of temperature, and also to economize the time of 
the attendants, an important object in large hospitals, recommended 
for these purposes the following dressing: Place over the diseased 
surface a piece of tulle or muslin, perforated with numerous holes to 
permit the free escape of pus, which is to be absorbed by a layer of 
soft old muslin wrung out of warm water and laid over the tulle ; 
this he calls the absorbent. The third layer, denominated the humec- 
tant, consists of a fine, thin, and porous sheet of amadou, also soaked 
in warm water, which it readily yields up to the muslin ; and lastly, 
to prevent evaporation, oiled silk is laid over the whole. This dressing 
requires to be renewed but once every ten or twelve hours; it permits 
the matter to escape freely, sustains the moisture, and keeps up a 
uniform temperature in the parts. 

Warm applications are extremely soothing in inflammatory affec- 
tions, accompanied with undue sensibility, pain, or soreness; they 
relax the tissues and promote the secretions and excretions ; and in 



IMMERSION. 89 

this respect are often efficient galactagogues. When cold water is 
disagreeable to the feelings of the patient in the treatment of fractures, 
gunshot wounds, and other injuries, warm water may often be substi- 
tuted for it with advantage. This dressing has been highly lauded 
in burns and scalds, where it is said to exercise a beneficial influence 
in mitigating the consecutive inflammation, rendering the consequences 
less severe locally, and the recuperative process more speedy than 
under other modes of treatment. 

Mr. Phillips has found the most intractable cases of eczema to yield 
to this mode of treatment in four weeks. 

Medicated Water-dressings. — Warm and cold water, chiefly 
the former, are sometimes combined with emollient, anodyne, astring- 
ent, and deodorant substances. The emollients enhance its soothing 
effects and confer the additional advantage of not requiring the 
dressings to be changed so frequently. 

The watery extract of opium, laudanum, the extract of belladonna, 
and other narcotics, increase the power of control of warm water over 
exaggerated sensibility of parts and excessive pain. 

In applying warm dressings to portions of the body affected with 
disease or injury, and disposed to hemorrhage, or discharging pus in- 
ordinately, the addition of the sulphates of zinc and copper, and the 
acetate of lead to the water will be advantageous. The solutions of 
the permanganate of potassa and the alkaline chlorides, tar water, and 
creasote, may be employed in like manner for correcting the fetor of 
suppurating and sloughing sores and wounds. 

Dry Fomentation is a name applied to the act of raising the 
temperature of parts of the body by the application of heated objects 
to them, such as billets of wood, bags of bran, chamomile, hops, &c. ; 
bottles filled with hot water, and bricks heated and wrapped in nap- 
kins. The object in view being to stimulate the vital powers depressed 
by the shock of severe injury, either accidental, or the result of a surgi- 
cal operation. In such cases, a blanket wrung out of hot water and 
wrapped around the patient's body, will also be found a useful means. 

It should not be forgotten, however, that where there is insensibility 
of the skin, paralysis, or concussion of the nervous system, the utmost 
caution must be taken that the temperature of these bodies be not too 
high, as the patient, from defective sensation, may be unable to give 
the practitioner warning of the presence of a destructive heat in con- 
tact with his person, and therefore a greater or less extent of the skin 
may be destroyed before it is discovered. 

Bottles filled with hot water should be carefully corked that no 
leakage occur and wet the bedclothes. 

Immersion. — Another mode of availing ourselves of the beneficial 
action of water in the treatment of wounds is by immersion. It has 
advantages in certain cases, and deserves our consideration. 

Percy remarks that in external diseases where the local heat is so 
exalted that it dries in a very few moments the thickest compress 
soaked in water, nothing would succeed better in restraining the 
violence of vital activity, and in restoring calmness and regularity to 
the organism, than plunging the part into a bath. Later, Langenbeck, 



90 WATER IN SURGICAL DISEASES AND INJURIES. 

of Berlin, used it with the happiest results in lacerated and contused 
wounds, and after surgical operations performed upon various parts 
of the body. In ordinary cases he kept the temperature of the water 
at about 70° Fahr., and never exceeded 86° ; where the inflammatory 
reaction was greater it was reduced to 50°. Baudens extolled a bath 
at 32°, a temperature at which he most frequently employed water. 

It can readily be imagined that there will be some little difficulty 
in the localization of baths in the continuity of the limbs, but as immer- 
sion is especially adapted to the treatment of inflammatory diseases 
of the fibrous structures of the hands and feet, and of burns, a common 
tub will be all that is required. This should be sufficiently large to 
hold such a volume of water that the heat of the part immersed will 
not elevate its temperature for some time ; perhaps three or four times 
a day the water will need renewal. 

On the other hand, when the disease is located at some intermediate 
part of the extremities, we will say at the knee, for instance, a special 
contrivance will be required ; and the one with which I have made 
my experiments answers very well. It consists of a wooden trough 
thirteen inches wide, eighteen long,, and twelve deep, with a sheet of 
India-rubber ten inches wide tacked to each end, and having at their 
unattached borders, or free margins, elastic cords which closely en- 
circle the limb, above and below, to prevent the egress of the water ; 
a glass plate may be laid over the trough at the option of the surgeon. 
To supply the apparatus with water of a uniform temperature, a 
reservoir — a keg or bucket will do — is placed near to and above the 
level of the bed, and connected with one of the upper corners of the 
trough by an India-rubber tube ; the corner diagonally opposite this 
is fitted with another tube to carry off the water and discharges from 
the wound into a basin resting upon the floor. 

When the limb is placed in the trough, the latter should be 
arranged a little lower than the plane of the body and somewhat 
inclined, so that the pus will settle towards its outer and lower corner, 
where the aperture of egress is placed. If the stump of an amputated 
limb is to be immersed, but one of these India-rubber sheets is unneces- 
sary, inasmuch as the box should then have four sides instead of three, 
as in the former case. 

The only dressings that need be applied in the case of wounds and 
stumps are a few points of suture and a few turns of a roller. 

In this manner may be treated the inflammations of the tendinous 
sheaths, and fibrous tissues of the palms of the hands and soles of the 
feet, contused and lacerated wounds, amputated limbs, and injuries of 
the joints. 

My experience with immersion has been limited to the two latter 
class of cases, and the results have been gratifying. 

Irrigations. — Irrigation is a method of applying water by per- 
mitting gentle currents to flow continuously over any portion of the 
body. It is of considerable antiquity, and the experience of surgeons 
all over the world attests to its great value as a therapeutical remedy 
in inflammations. 

Various kinds of apparatus have from time to time been suggested 



IRRIGATIONS. 



91 



to effect irrigation, but one of the simplest, and at the same time as 
efficient as any other, however complicated, consists of a common tin 
pot or wooden bucket, with its bottom perforated with a few holes, 
through which pieces of common wick are thrust, so as to permit the 
water to run in a fine stream. The bucket should be affixed by a cord 
to the ceiling or to a hoop spanning the patient's bed. 

The apparatus (Fig. 60) used by Velpeau at La Charite consists 
of a reservoir with a tube projecting downwards from its bottom, and 

Fi . 60. 




Velpeau's apparatus for irrigation. 

crossed at right angles by another tube, furnished with a number of 
hollow stems placed at equal distances upon its length. The supply 
of water is regulated by a stopcock upon the vertical tube, and it flows 
out in a number of slender streams to fall upon the diseased part. 
The reservoir is suspended in the manner above mentioned. 

The limb to be irrigated is placed upon a sheet of India-rubber 
spread out upon the bed, and so arranged that none of the water shall 
escape upon the bedclothes or the person of the patient, but may run 
directly from the limb into a vessel upon the floor near the bed. 

To prevent splashing by the fall of the fluid upon the part, it may 
be covered with a single piece of linen. 

As to the duration of the irrigation surgeons have differed in 
opinion ; while some discontinue its use after five or six days, or as 



92 WATER IN SURGICAL DISEASES AND INJURIES. 

soon as suppuration is established, others advocate its continuance for 
thirty and even sixty days, or until cicatrization has begun. Yet it 
would seem to be the best rule to abandon irrigation as soon as inflam- 
matory action has been subdued and we have nothing further to fear 
from it, without regard to time or the number of days which may 
have elapsed. 

It will be well, also, to take care that no rapid transition of tempera- 
ture occurs, by simply using the cold water-dressings for two or three 
days after abandoning irrigation. 

With a similar view the temperature of the water at the beginning 
of the treatment may be in the neighborhood of 76°, or about that of 
the healthy skin, and then gradually lowered until the desired degree 
of cold is obtained. 

M. Malgaigne gives the preference to continued irrigation over every 
other method of treatment in wounds and inflammations not very deep- 
seated, and particularly wounds from .fire-arms, and those of the hands 
and feet ; while for other wounds he prefers intermittent irrigations. 

Some discrepancies of opinion also exist as to the relative advantages 
of cold and warm irrigations. Nelaton would restrict the former to 
lacerated and contused wounds below the knee and elbow, while he 
allows greater latitude to warm irrigation. 

Velpeau observes : " I have remarked, also, that it (cold irrigation) 
readily promotes a mortification of the parts when the wound was 
accompanied with extensive separations, or that it occupied some parts 
of the fingers or the hand, or the extremities in general. I have 
observed, in fact, that while it prevents or diminishes the redness of 
the skin, and the tumefaction of the deeper tissues, it often masked 
inflammation, rather than prevented or destroyed it ; that, therefore, 
it does not prevent the purulent discharges, and that there finally 
resulted from all this a thin suppuration of a bad aspect, a general con- 
dition of things of a more serious nature, and a disposition in the 
wound less favorable to cicatrization than by other kinds of dressing." 

Sanson states that tetanus resulted in one case of a burn treated by 
irrigation, and Legouest adverts to it as very often retarding or mask- 
ing the appearance of inflammation, instead of preventing it ; while, on 
the other hand, Josse and Grosselin regard it of immense service in 
fractures, dislocations, erysipelas, phlegmon, and all kinds of inflam- 
mations in connection with wounds. 

M. Chassaignac has used irrigation of the eye for the treatment of 
the ophthalmia of young infants, and several inflammatory conditions 
of that organ, and also especially for the removal of opacities of the 
cornea which resist ordinary means ; he reports remarkable success 
from the plan in these cases. The child is laid on a table, and water 
allowed to flow from a small vessel through a tube over the surface of 
the eye, during from five to fifteen minutes, several times a day. 

Cold Irrigation. — The first effects of cold irrigation are to diminish 
the temperature of the parts to which it is applied, and to cause a pain- 
ful sensation that is soon followed by one of the opposite character. 
Yet this is not always the case ; for some patients suffer severe pain 
even during the whole period of irrigation. In this case its use is 



IRRIGATIONS. 93 

clearly contra-indicated. Indeed, we have no better guide in applying 
cold water than the sensations of the patient. 

In gunshot wounds and other injuries attended with shock to the 
nervous system, and depression of the vital activity of the injured 
parts, reaction should be first fully established before the cold water 
is had recourse to, as gangrene may readily be induced in them. Also 
when from any cause there is a tendency to gangrene, its employment 
is contra-indicated. 

As the degree of reaction in a part is in direct proportion to the 
intensity of the cold, it can readily be imagined that the intermittent 
use of cold water may induce a series of reactions in an inflamed 
organ exceedingly prejudicial. 

The object of cold water, as a surgical dressing, is to obtain its 
refrigerant effects ; therefore, to avoid the shock and subsequent reac- 
tion, its temperature should be at first but a few degrees below that of 
the healthy skin, and its volume greater than will be necessary at a 
subsequent period when its temperature is lowered. 

Warm Irrigations. — The method of applying warm water irrigation 
differs in no particular from that already described for cold water. It 
may be employed in those cases where the contact of cold water with 
the body produces painful sensations, or where, from the extent of the 
injury and the depressed condition of the nervous system, cold would 
be likely to dispose the parts, already deprived to some extent of 
their recuperative energy, to mortification. 

Irrigation of the Nasal Fossae. — When a foreign body gains admis- 
sion into the nares, and cannot be dislodged by the ordinary means, 
a stream of water thrown from the direction of the pharynx will often 
effect it. 

The sedative effects of cold water, or the emollient ones of warm 
water can be obtained in the same manner in inflammatory affections, 
ulcerations, or other morbid changes of the mucous membrane lining 
that cavity. 

The advantage of the plan is that any liquid can be brought, 
continuously, in contact with the entire extent of surface of the nasal 
fossae and pharynx ; while by inclining the patient's head forward, no 
part of it flows into the gullet or trachea. 

Solutions of the nitrate of silver, the bichloride of mercury, the sul- 
phates of zinc and copper, or any other metallic salt, or astringent sub- 
stances may, likewise, be successfully used in the treatment of chronic 
coryza and ozasna. I have lately cured a case of the latter disease of 
long standing, in a young man, by the injection of a strong solution of 
nitrate of silver. 

The apparatus which I have constructed for this purpose consists 
of a long slender tube of vulcanized rubber, bent at its distal extre- 
mity into a hook, the point of which is perforated with four holes, 
while the proximal end is furnished with a male screw to fasten to a 
syringe, or to the India-rubber ball pump, according as an intermit- 
tent or continuous action of the fluid is required. I always employ 
the syringe when using strong solutions of the metallic salts. 

The best manner of making the injection or irrigation is to place 



91 



WATER IN SURGICAL DISEASES AND INJURIES. 



the patient in a chair facing the window, with his head thrown back 
and his mouth widely open. The operator then passes the long tube 
held in his right hand through the fauces, and hooks its point behind 
the soft palate, and after flexing the patient's head, he forces the fluid 
into the nares, the former running from the nose freely. 

Irrigation of the Bladder. — Diseases of the bladder, such as inflam- 
mation, hemorrhage, and stone, are sometimes very much benefited 
by warm or cold irrigations. It can be accomplished by the double- 
tubed catheter seen in the figure. (Fig. 61.) The dotted line indicates 

Fig. 61. 




Double-tubed catbeter. 

the septum of division, and the arrows the course of the fluid, as it passes 
along the upper compartment to issue from the hole upon the con- 
cavity of the curve into the bladder, when it again enters the cathe- 
ter by the hole upon the convexity to emerge through the lower divi- 
sion, externally. The wire stylet (c) is used to keep the catheter 
clear of clots of blood, sabulous matters, or other obstructions. The 
water injected may be simple, or variously medicated to answer spe- 
cial indications. It is forced through the instrument by a syringe, or, 
what is better, the India-rubber ball pump. 

Irrigation of the Uterus and Vagina. — For the purpose of irrigating 
the vagina and uterus various contrivances have been invented, but 
none of them are so elegant and useful as that of Maisonneuve. It is 
extremely ingenious, and deserves a particular notice in this place. 

As seen in Fig. 62, the vaginal portion of the apparatus consists of a 
hollow frustum of a cone of ebony or vulcanized rubber with vertical 
slits, and sufficiently large to distend the vagina moderately. Through 
this cone runs a metallic tube terminating at its apex in a perforated 
disk like the rose of a common watering pot; the proximal end of the 
tube projects from the base of the cone, and has attached to it a long 
flexible India-rubber tube with a rubber ball pump upon its middle. 



WATER BY MEANS OF INDIA-RUBBER SACKS. 



95 



Another tube of the same Fig. 62. 

material is attached to the 

base of the cone, near the 

former, to carry off the waste 

water entering it through 

the slits. 

The patient can use the 
instrument herself without 
wetting her person or the 
bedclothes, by simply re- 
clining upon her back with 
the cone introduced into the 
vagina, then by pressing 
upon the ball grasped in 
the hand the water will be 
forced from the basin, in 
which the bell-shaped ex- 
tremity of the tube is im- 
mersed, into the vagina. 
Another vessel should be 
placed near the bed to col- 
lect the waste water from 
the discharging tube. 

A number of uterine and 
vaginal diseases may be 
advantageously treated in 
this manner, such as obsti- 
nate cases of leucorrhcea, 
which will often yield to 
the continued use of cold 
water. It is a good way of 
applying cold in uterine 
hemorrhage, and astrin- 
gent solutions in inflamma- 
tory affections of the vagi- 
nal mucous membrane. 

The Application of Water by Means of India-rubber Sacks. — 
There are some disadvantages attending irrigation, such as the difficulty 
of keeping up a uniform temperature, the wetting of the patient or the 
bedclothes, the disposition of the cold water to cause inflammatory 
affections of the chest, and lastly, in some instances, the inability of 
confining the water with precision to any given part by the restless- 
ness of the patient, or from his tender age precluding the exercise of 
proper judgment. 

Although the present method, in a measure, does away with these 
disadvantages, yet it is not itself free from all objections and incon- 
venience : of which we may instance as the principal the weight of the 
sacks, and the expense attending their manufacture. 

I am convinced by numerous trials that there are cases in which 
their utility is incontestable. Two cases of perforating fracture of the 
skull with cerebral inflammation came under my care in which the 




Maisonneuve's irrigator. 



96 



WATER IN SURGICAL DISEASES AND INJURIES. 



delirium was such that it was impossible to keep any kind of dress- 
ings upon the head without having present two or three persons to 
restrain the violence of the patients. Here the ice cap answered an 
admirable purpose, as it could be securely fastened to the head by 
means of the chin straps attached to it. In such cases the ice blad- 
ders will not answer any better than cold water-dressings, for their 
very shape, when filled with ice or cold water, will cause the edges 
to bulge to such an extent that it would be impossible either to 
cover the head entirely by them, or to retain them in place unless by 
the assistance of attendants. Besides, in my experience in the hos- 
pitals during the late war, bladders were not attainable while there 
was an abundance of oiled silk to be found, of which a very good 
substitute for the India-rubber cap can be made. 

The heat of the scalp is such, at times, that the water in the bladders 
is soon rendered warm, and needs frequent renewal, in the same man- 
ner as the cold water-dressings. These disadvantages are perfectly 
overcome with the India-rubber cap, which covers the whole head 
above the face and ears, and can be so secured by the ribbons tied 
beneath the chin that the patient cannot displace the cap by his rest- 
lessness ; it does not permit the water to run over his neck and chest, 
and thus produce chills, colds, and even inflammatory affections of the 
thorax. With a supply tube of India-rubber, and another of discharge, 
water of any temperature can be kept constantly passing through the 
cap, thus securing a never-varying temperature, a condition essential 
in the correct treatment of inflammation by cold. 

The Cap (Fig. 63) is composed of double layers of India-rubber cloth 
formed somewhat in the shape of a helmet. With the interior of this 
two India-rubber tubes communicate, one for sup- 
plying the water from a vessel while the other (c) 
conveys it away from the cap to a basin. By 
means of the stopcock of the reservoir, the flow 
of the fluid is regulated, so that a constant supply 
of uniform temperature reaches the head. At the 
apex of the cap is seen an orifice (b) communicating 
with the scalp and furnishing a ready outlet for 
the perspiration. 

Besides the cases I have already mentioned, 
in which the cap has been used advantageously, 
I may also mention all those diseases attended 
with vascular or cerebral excitement, obstinate 
cephalalgia, and especially that resulting from 
the effects of an inordinate indulgence in alco- 
holic stimulants. In a very few moments the 
sedative action of the cold water is marked, the 
pain disappears, and the patient, before tossing 
about insomnious, becomes quiet and finally falls into a gentle sleep. 
The Cervical Sack. — In affections of the neck and throat we can also 
avail ourselves of the advantages of hot and cold water by means of 
the cervical sack which fits those parts and rests upon the shoulders 
and the upper part of the sternum. 



Fig. 63. 




India-rubber cap for apply 
ing cold water to the head 



WATER BY MEANS OF INDIA-RUBBER SACS. 97 

The Spinal Sack. — This has recently been much used in obstinate 
cases of spinal tenderness or pain, and in diseases depending upon vas- 
cular congestion of the cord. Mr. Chapman, of London, recommends it 
highly in cholera. This gentleman remarks: " The bags I use are of 
different lengths; of the width already named" (four to four and a 
half inches) " for adults, and of lesser widths, of course, for children. 
I have had them made both of India-rubber and of linen with a sur- 
face of India-rubber upon it ; the former are the best. The width of 
the bags is equal throughout, except at the opening, which is narrowed 
to facilitate tying, and elastic to admit easily the lumps of ice. When 
the bag is full, I divide it, if a large one, into three segments ; this can 
be done by constricting it forcibly with a string ; the ice of the upper 
part is thus prevented from descending, as the melting goes on, into 
the lower part of the bag." He bases the employment of the spinal sack 
upon the belief that a " controlling power over the circulation of the 
blood in the brain, in the spinal cord, in the ganglia of the sympathetic 
nervous system, and through the agency of these nervous centres, 
also in every other organ of the body, can be exercised by means of 
cold and heat applied to different parts of the back. In this manner 
the reflex excitability, or excito-motor power of the spinal cord, and 
the contractile force of the arteries in all parts of the body, can be 
immediately modified." 

The facility of passing alternately hot and ice-cold water through 
these sacks will recommend them in the treatment of bed-sores after 
the plan of Brown-Sequard, which consists in the alternate application 
for ten minutes or more at a time, of iced water and hot poultices. 

The Thoracic Sack will enable the physician to surround the chest 
with water of any temperature, the utility of which in inflammatory 
disease of the thorax, as pneumonia and bronchitis, is undoubted. We 
have already spoken of the advantages of the oil-silk or India-rubber 
jacket in this class of cases, and we have only to remark that its 
action is somewhat similar to that of the thoracic sack supplied with 
warm water, differing only in degree. 

The Abdominal Sack is constructed upon exactly the same principles 
as the cap, and will be found useful in the treatment of colic, spasms 
of the intestines, in the passage of a gall-stone, strangury, and inflam- 
matory affections of the abdominal organs, particularly peritonitis. 
M. Behier, at the Session of the French Academy of Medicine, April 
1, 1862, stated that, " since October, 1858, 801 females were confined 
at the Hopital Beaujon ; to 355 of these females ice was applied ; 24-i 
of the patients presented merely swelling of the annexes of the uterus, 
accompanied with slight pain, which soon disappeared. In 68 the 
symptoms were of a more menacing character, with a decided febrile 
reaction and a commencing alteration of the patient's features. 39 of 
the 801 parturients died. But even in these cases the application of 
the ice postponed the fatal result beyond the customary period at 
which it happens in cases where ice had not been applied." The ice 
was retained in contact with the abdomen by means of caoutchouc bags. 

The thoracic and abdominal sacks may be joined, when the object is 
to stimulate the system powerfully, by hot water applied to a large 
7 



98 WATER IX SURGICAL DISEASES AND INJURIES. 

extent of the surface, as in the collapse from cholera, severe injury, 
etc. This plan is superior to that of applying hot bricks, bottles of 
water, etc., which, besides being troublesome, are continually under- 
going variations in temperature, and come in contact with only a very 
limited extent of the skin. 

The Scrotal Sack may be used in orchitis, spasmodic stricture, and 
retention of urine, etc. 

Water Cushions, of any desired shape or size, may be constructed 
in the same manner, and used in the treatment of fractures of the 
extremities and the spine. 

Sacks for the Upper and Loiver Extremities. — In the few cases of 
chronic rheumatism in which I have tried warm water, by means of 
these sacks, advantage was obtained in the mitigation of the pain, and 
thus the patient's condition rendered more comfortable. 

SECTION II. 

THE USE OF WATER GENERALLY— BATHING. 

"We have already alluded to the antiquity of bathing, both as a 
sanative measure and as a luxury, and also of its universal employ- 
ment at the present time for this twofold object. "We propose here 
to consider it only in its surgical relations and uses. 

Baths may be classed either according to the nature of the medium 
into which the body is immersed, or according to the extent to which 
the body is immersed into that medium. By the first method baths 
are arranged into the simple water, the vapor, and the dry baths. 

But the second plan, which divides baths into general and local, 
will answer our purpose better, and we shall therefore adopt it. 

General Baths. — General baths are either simple or medicated ; 
and they vary in their therapeutical effects according to the tempera- 
ture of the water employed, the manner of its application, and the 
nature of the medicinal impregnation. 

The thermometer may be relied upon as a general guide in using 
baths, but the sensations of the patient will alone indicate the precise 
effects of bathing ; for the reason that a temperature which for one 
person might give the sensation of cold, will in another produce one 
of an opposite character. Though Dr. Forbes has thought that it 
would be convenient to decide upon some particular temperature as 
the dividing line between these two classes of sensations, and he has 
selected that of 85° Fahr. ; denominating all baths of a temperature 
above this warm, and all those below it cold. 

Influenced also by motives of practical utility in their employment, 
he advises a further classification: A. Cold Baths. — 1. The Cold 
Bath, from 33° to 60° ; 2. The Cool Bath,. 60° to 75° ; 3. The Tem- 
perate Bath, 75° to 85°. B. Warm Baths.— 1. The Tepid Bath, 
85° to 92° ; 2. The Warm Bath, 92° to 98° ; 3. The Hot Bath, 98° 
to 112°. 

It will be seen that in "these baths we obtain a range of 79° of tem- 
perature, from 33° to 112°, which will be found amply sufficient for 



BATHING. 99 

all practical purposes, though occasionally a higher degree than 112° 
has been resorted to. 

The immediate effects of an immersion in water between 32° and 
35° of temperature are horripilation and numbness of the surface, con- 
vulsive anhelation, tremblings of the limbs, chattering of the teeth, 
and pain in the head ; these effects will be more marked if the body 
changes its position so as to bring fresh quantities of cold water in 
contact with the skin. If the immersion is continued five or six 
minutes longer, violent pains in the stomach and acute pains along 
the course of the muscles will ensue ; the pulse becomes quick and 
small, the respiration accelerated and oppressed, and the general 
sensibility much blunted. A longer stay yet in the water, and these 
symptoms will be followed by stupor and death. 

If the temperature is more elevated, and the patient in vigorous 
health, other phenomena show themselves ; the vital powers are roused 
into an increased activity, so that the shock is soon followed by reac- 
tion, the pulse expands, the respiration becomes freer, and the unplea- 
sant sensations give way to others of an agreeable kind, a glow dif- 
fuses itself over the surface, and the patient feels as if possessed of 
renewed strength. 

After a longer or shorter period, according to the degree of cold 
and the activity of the constitutional powers, if the bath is continued, 
the vital activities within cease to struggle so energetically with the 
physical forces, and in consequence, reaction will be succeeded by a 
sensation of cold, the phenomena at first described will reappear, and 
the system will become powerless and exhausted. 

We observe clearly in all these phenomena three elements, viz., 
shock, refrigeration, and reaction, which it is important to separate, 
as each has its own individual action and influence upon disease. For 
instance : in torpor of the nervous system, as in syncope, we dash cold 
water in the face to rouse it into action by the shock impressed ; here 
any degree of refrigeration would be pernicious, while, on the other 
hand, in febrile disturbance and acute inflammations we endeavor to 
obtain the refrigeration without the first and third elements. 

We have already spoken, elsewhere, of the injurious effects result- 
ing from the intermittent application of cold water in local inflamma- 
tion, and feel convinced that often more injury than good results from 
its use in many cases from want of due consideration of its physiologi- 
cal effects. 

As a therapeutical agent, cold bathing is one of the most powerful 
tonics in the whole range of the Materia Medica, and hence its great 
use in debilitated conditions of the system. In these cases, however, 
care should be taken that the temperature be not too low, for desirable 
as such a temperature may be as a corroborant, we should not, on the 
other hand, forget that a fatal languor may be induced. 

The cool bath from 60° to 76° will answer very well as a tonic in 
debility as well as for persons advanced in years, and for the young 
who do not bear cold as well as the middle aged and vigorous. The 
shock is slight, and in a little while the skin glows with a delightful 
freshness. 



100 WATER IN SURGICAL DISEASES AND INJURIES. 

Water near the temperature of the skin produces little other effect 
beyond the mechanical action of its weight, and may be employed 
for the purposes of cleanliness, and where the object is to remove 
adhering dust or crusts which plug up the exhalant orifices and de- 
range the perspiratory function, and thereby cause sensations of itching, 
and a pimply skin. 

The warm bath, 92° to 98°, produces results opposite to those of 
the cold bath, giving rise to pleasant sensations when the body is 
immersed in it, gently exciting the skin, and favoring transpiration. 
It soothes the nervous system, relieves pain, and at the same time 
excites it to healthy action ; it promotes the circulation, and thereby 
favors an equable distribution of the blood through the whole system. 

The hot bath of 100° and upwards is still more stimulating, pro- 
ducing increased action of the vascular system ; the heart beats more 
rapidly, and the vessels of the head sometimes throb painfully, while 
the superficial vessels are gorged with blood. 

Soon, however, this increased action gives way to a corresponding 
degree of relaxation, a profuse perspiration breaks out upon the sur- 
face which relieves the general tension of the vessels. The patient 
will then labor under a lassitude for some time after coming out of the 
bath. 

When the body is sponged with water from 120° to 130° tempera- 
ture, or immersed in a bath of a temperature that the patient can bear 
without pain, the skin becomes hot, red, and dry, and remains so for 
some time, little or no sedation being observed to follow. My atten- 
tion was first called to this effect of hot water some years ago by a 
French gentleman, a traveller in India, who was in the habit of having 
constant recourse to it when about to begin a long and fatiguing jour- 
ney under a torrid sun, and also after completing it. He assured me 
it gave him greater endurance and checked profuse perspiration. The 
remedy will be of service in those diseases attended with undue per- 
spiratory activity, as in phthisis. 

When removed from the warm bath, the patient should be carefully 
dried with a coarse towel, and sheltered from drafts of air and the 
inequalities of temperature of his chamber. 

As a sedative the warm bath is used to assuage the pain from vio- 
lent muscular contractions, as in colic and cramps, and to relax the 
muscles during the operation of the taxis, and spasmodic contraction 
of the neck of the bladder. 

As an indirect tonic it may be employed in debility, and as a stimu- 
lant in extreme exhaustion with a concentration of the nervous ener- 
gies and circulating fluids upon the interior organs. In chronic skin 
diseases, also, the warm bath is advantageous as a stimulant to alter its 
physical and vital states. 

Here we can see that the stimulant effects of a warm bath may be 
separated, to some extent, from the sedative effects, simply by the 
method of its application : an important object in cases of debility in 
which any amount of sedation would be pernicious. To accomplish 
the object the bath should be of a temperature from 98° to 112°, and 
continued for a few moments only. 



BATHING. 



101 



In large cities baths may be obtained at any time, and even in 
private dwellings the most elaborate arrangements may be found for 
this purpose. Where these conveniences are not attainable, the simple 
contrivance (Fig. 6-1) recommended by Dr. Thomson will answer the 
purpose. 

He describes it as "consisting of a hammock (a) of Macintosh's 
cloth, which is extended upon two long poles (bb), passed through a 



Fig. 64. 




Thomson's bathing apparatus 

broad seam on each side of the hammock, and kept asunder by the cross 
pieces (cc) which are attached to the pole by the thumb-screws (ddd). 
At one end of the hammock is an air pillow, which can be readily 
blown up, and below it is a flexible tube (/) made of the same mate- 
rial as the hammock, by which any water it may contain can be 
readily drawn off. When the poles are fixed, as in the above figure, 
and the open end of the flexible tube is twisted around one of the 
thumb-screws, the bath is ready to receive the water. It may be sup- 
ported upon two chairs, or upon folding tressels (ee). The advantage 
of this bath is, that it requires a very small quantity of water com- 
pared to that demanded for other baths ; that it requires no sheet for 
the bather to rest upon; and when the bathing is completed, the 
poles and the folding tressels can be placed aside in a small closet 
or in the corner of a dressing-room, and the hammock, when dried, put 
into a drawer." 

For portability I have adopted a bathing-tub made of India-rubber, 
and having hollow walls, between which air is forced by means of a 
pair of bellows. After the tub has been used it should be wiped dry 
and the air squeezed out of its walls, when it may be folded up in a 
small package and kept in a drawer. 

In the absence of either of these contrivances, a common washing 
tub or large barrel may be used instead. 

The Shower Bath may be either general or local, and its effect will 
vary with the temperature, volume, and the height from which the 
water falls upon the patient, but their general character will be pretty 
much the same as those of the plunge bath of the same temperature. 
It possesses the advantage, however, of enabling the practitioner to 
localize the action of the water in such a manner that the shock and 
diminished temperature may be brought to bear directly upon any 
given part, and thus any general perturbation of the system will be 
avoided, if it is so desired. 



102 WATER IN SURGICAL DISEASES AND INJURIES. 



Again, some patients cannot bear the mechanical effects of the water 
of a plunge bath upon their bodies, as it produces a feeling of suffoca- 
tion and an indescribable sense of uneasiness : here the shower bath 
will be found an efficient substitute. 

In many dwellings shower baths are arranged in such a manner 
that, by means of a stopcock furnished for the purpose, the force and 
quantity of the falling water may be increased or diminished accord- 
ing to the tolerance of the patient. 

A portable shower bath (Fig. 65) is now manufactured, consisting of 
a tin vessel of half a gallon, or a gallon capacity, with its bottom per- 
forated with numerous holes. Its inte- 
rs- 65 * rior communicates with the air through 
a small tube running in the handle of 
the vessel, and terminates at its top by 
a small hole which can easily be covered 
with the pulp of the index finger. 

When we desire to use the vessel it 
should be immersed in a pail of water, 
and the orifice above spoken of closed 
with the point of the finger, which will 
cause the water to be retained in the 
vessel, after it is lifted from the pail, 
by atmospheric pressure. 

The patient may now hold the tin 

over his head, and by raising the finger 

from the hole the water will shower 

upon his person. 

Portable shower bath. Affusion is a rude sort of shower bath, 

and consists in simply dashing water 

from a bucket over a person, yet it produces much less shock than the 

former. 

The vapor bath resembles, in its general effects, those of the warm 
bath already described, the chief points of difference being that, at 
corresponding degrees of temperature, the vapor bath is more sudo- 
rific and derivative, while at the same time it is much less stimulant 
and soothing to the nervous system, cseteris paribus, than the warm 
bath. 

If the whole body is immersed in the vapor, which is breathed at 
the same time, its heating effects will be much increased, because the 
inhalation stops the cooling process taking place by evaporation from 
the luugs, and also furnishes just so much more space for the heating 
medium to act upon, as there are square inches of bronchial surface. 
Hence, it will be necessary, under these circumstances, to employ vapor 
of a lower temperature than where the exterior of the body alone is 
exposed. 

The physical law is, that the heating power of a medium depends 
upon its density, conductivity, and capacity for caloric, being greater 
where these properties are possessed in greater degree: it follows 
then that the relative heating power of water and vapor will differ 
considerably. 




BATHING. 



103 



The ratio of difference is expressed in the following comparative 
view drawn up by Dr. Forbes : — 







Vapor. 




Not breathed. Breathed. 


Tepid bath .... 
Warm batli .... 
Hot bath .... 


85°— 92° 

92° — 98° 

9S°— 106° 


96°— 106° 
106°— 120° 
120°— 160° 


90°— 100° 
100°— 110° 
110°— 130° 



The cases in which the vapor bath is employed are marked by the 
retrocession of the fluids upon the central organs, as in the cold stage 
of fever and the collapse of cholera. It is also used to alter the action 
of the skin in cutaneous diseases, and to remove the stiffness and 
rigidity of the muscles and joints. 

Local vapor baths have also been recommended and employed by 
Dr. Macartney in painful wounds, contusions, and fractures. In otitis 
and otalgia a stream of warm vapor may be introduced into the ex- 
ternal meatus by means of a funnel inverted over a vessel of hot 
water, the small end being placed in the meatus. The vapor bath is 
also occasionally medicated with the volatile and odoriferous constitu- 
ents of certain plants and balsams. 

Blegborough recommended an air-pump vapor bath in gout, rheu- 
matism, and paralysis. 

There are elaborate apparatus sometimes prepared for the adminis- 
tration of the vapor bath, but generally an extemporized apparatus 
that can be gotten up in any household will serve pretty nearly as 
well. 

If the patient can sit up, place him upon a stool under which a 
basin of hot water is introduced, and surround him with a thick 
blanket, or a sheet of India-rubber cloth, in such a manner that it may 
hang down, all around, upon the floor : if he is not to breathe the 
vapor, it should be fastened above, around his neck. In the contrary 
case, the head may be inclosed and the blanket supported above it by 
a common keg-hoop firmly tied to the top of a stick, bound below to 
one of the legs of the stool. 

Everything being now ready, a hot brick is placed in the basin, 
from the water contained in which steam will rise in abundance and 
fill the space between the patient's body and the blanket. 

Another plan quite as simple is to reverse over a patient, seated 
upon a stool, a common wicker basket with a hole in the side for the 
patient to protrude his head at pleasure. The basket is covered with 
a blanket likewise perforated, and the steam is admitted from below 
by means of a tube coming from the spout of a teakettle filled with 
water and kept boiling upon a fire near at hand. 

If the patient is confined to his bed, the blanket may be supported 
over his person by two or three hoops nailed to a piece of stiff wood 
five or six feet long. The steam is obtained from a boiling kettle, as 
in the former case. 

Dr. J. B. Nevins, of Liverpool, has suggested a very simple method 



10-1 WATEE IN SUKGICAL DISEASES AND INJUEIES. 

of employing a vapor bath while the patient rests in his bed : he 
directs that " two pieces of coarse flannel (common scouring cloths 
answer the purpose admirably) are to be soaked in common vinegar, 
about a pint being necessary for each cloth. Two common bricks 
are then to be heated nearly red-hot in the fire, folded up in these 
flannels, and placed on two plates. The patient being stripped, one 
plate is to be put a little distance from one knee, and the other a little 
distance from the opposite shoulder, and the patient is to be covered 
over with the bedclothes. In a few minutes he is surrounded by a 
most refreshing steam bath, which produces a warm, agreeable per- 
spiration, that may be kept up for twenty minutes or longer, if the 
bricks retain their heat sufficiently." In this manner, he says, he has 
treated acute rheumatism for a number of years, with great success, 
always following the vapor bath with the cold douche, which is accom- 
plished in this way : "As soon as it is decided to remove the bricks, 
the patient, still in bed, is to be very rapidly mopped all over with 
towels wrung out of cold water, then immediately wiped dry with dry 
towels, supplied with a warm shirt or flannel garment, and covered 
with a fresh, dry sheet, etc., or with blankets alone, as may be most 
agreeable to him." 

"The cold water application immediately on the removal of the 
hot vapor is very important, as it prevents the continuance of an 
enfeebling perspiration after the hot bath." 

The Warm Air Bath possesses some of the qualities of the vapor 
bath. It is more stimulating and sudorific than the latter, but much 
less soothing and relaxing. It may be employed in the same class of 
cases, and more especially in the dry scaly eruptions of the skin. The 
sudatorum of Dr. Gower is made with hoops, in the same manner as 
the apparatus for the vapor bath already described ; the tube commu- 
nicating with its interior has a bell-shaped opening externally, under 
which a spirit lamp is to be placed. He states that a temperature of 
85° produces a profuse perspiration, and that above this " the effect 
would be rather frustrated, owing to the ardent heat which the patient 
feels and complains of, without obtaining the relief which sweating 
invariably produces." 

Dry Baths consist of some solid matters into which the body is 
immersed. Formerly the buccaneers of the West Indies were in the 
habit of burying those of their comrades affected with scurvy up to 
their necks in the sand, the warmth of which produced copious per- 
spiration. 

A disgusting practice, still pursued by the common people in some 
parts of the world, is to immerse patients in the blood of recently 
killed animals, mud, masses of the husks of grapes, the refuse of the 
olive after the oil is expressed, and other like matters. 
. The warm skins of animals just dead, particularly that of the sheep, 
wrapped around the body of the patient, with the wool side outwards, 
have in the opinion of some produced good results ; the celebrated 
Marshal Lannes, Due de Montebello, being treated in this manner 
after a severe injury he received by a fall from his horse. 



LOCAL BATHS. 105 

Local Baths. The Douse or Douche Bath. — We must place at the 
head of local baths the douse, which is, perhaps, more frequently em- 
ployed in surgical practice than most any other form of local bathing 
whatever. It consists in directing a stream of water upon some part 
of the body, and it depends for its efficacy upon the temperature of 
the water and the volume and height of the stream. 

Passing rapidly over the surface, the particles of the water are 
always cool, and thus it becomes a most powerful refrigerant, while 
the percussion and the weight of the water actively stimulate the 
capillaries. 

The douse may be either cold or warm, its stimulating, refrigerant, 
and tonic qualities diminishing with the increase of temperature. The 
warm douse may be borne as high as 180° Fahr., but it is seldom 
employed. Its stimulating effects are direct, and not, like those of 
the cold douse, the result of a reaction subsequent to a primary seda- 
tion. 

The douse, affording as it does a wide range of temperature from 
33° to 180° Fahr., is applicable to the treatment of numerous diseases. 
In chronic affections of the joints it enjoys a high reputation, the 
diseased part being subject to the current for fifteen or twenty minutes 
three or four times a day. 

As a tonic in general debility it is also valuable ; the patient, if 
very weak, may begin with a more elevated temperature, and subse- 
quently reduce it to 40° or thereabouts. 

Paralysis, not depending upon acute disease of the brain, may also 
be benefited. Although the douse has been recommended in the acute 
phlegm asise, yet great caution should be observed in its administra- 
tion, lest more injury be done than good conferred. Chronic headache, 
and several species of neuralgia, especially sciatica, have yielded to its 
influence. 

Old glandular swellings, and old ulcers verging towards the class 
of the opprobria medicorum, have sometimes happily given way to its 
persevering use. 

In weak eyes, and in some of their inflammatory diseases, Beer 
employed a special apparatus for applying the douse to the eye. It 
consists of a double tin vessel, the outer one for containing the ice to 
cool the water contained in the inner compartment ; from the bottom 
of the latter a long tube projects, with its inferior extremity bent back 
upon itself, and drawn out to a small orifice from which the water 
falls upon the diseased eye. 

Graefe used for the same purpose a common siphon, with its short 
leg immersed in water contained in a vessel, while the extremity of. 
the long limb has a gutta-percha collar fitted to it, by means of which 
nozzles of any calibre may be attached to the tube, to direct the stream 
of water in any direction. 

Formerly the douse was much used in the treatment of mania, and 
it is stated that a column of water twelve feet high, allowed to fall 
vertically upon the head, produces such intensely painful sensations 
that the most furious maniac who has once experienced its effects will 
be awed by the mere threat of its application. 



106 



INJECTIONS, 




The Hip-bath (coxasluvium) is a powerful derivative remedy in 
diseases of the organs contained in the abdominal and pelvic cavities 
and the lower portion of the spine, and may be 
Fi g- 66 - had recourse to in cases where general bathing 

might be contraindicated in consequence of disease 
of some of the great vessels or interior organs; it 
is also beneficial in strangury and prolapsus ani, 
in the latter case the addition to the water of some 
astringent substance would be advantageous. 

The vessel used for applying the hip-bath is 
seen in the figure (Fig. 66). 

The Foot-bath (pediluvium) is also used as a 
vessel for hip-bath. revulsive and counter-irritant in catarrhs and de- 
terminations of the blood to the head. 
The water should be as hot as the patient can bear without pain, 
and made more stimulating yet, if it is desirable, by the addition of 
mustard, a quarter of a pound of cayenne pepper, or a handful of salt. 
Twenty minutes will be a sufficiently long time for the feet and legs 
to be immersed in the water. The bath should be taken while the 
patient is in bed, with his feet hanging over its edge ; or, if he is 
sitting up, his person should be protected by a blanket. 

Other local baths have been recommended, which are only limited 
in number by the different parts of the body to which they can be 
applied. They are of real utility in many cases; for instance, in those 
persons who have a tendency to free and distressing perspiration from 
the axillae, hands or feet, or other parts of the body, water, as hot as 
can be borne, will relieve the annoyance to a considerable extent. 



CHAPTER V. 



INJECTIONS. 



Injection is the operation by which, with an instrument called a 
syringe, we are enabled to bring fluids of various kinds in contact 
with the internal walls of the different canals and cavities, whether 
natural or artificial, of the human body ; the fluid injected also bears 
the same name. Injections are exceedingly numerous and varied, 
according to the character and locality of the cavity to be injected, as 
well as the nature of the fluids employed. 

Simple tepid or cold water is often used to wash out pus or other 
secretions from the irregular passages produced by suppurative action 
or wounds, and where other means could not be used at all, or, at 
least, would be painful or pernicious to the delicate granulations. 

The injected fluid is either simple water of various degrees of tem- 
perature, according to circumstances, or water medicated with emol- 
lient, narcotic, astringent, or irritative substances. We shall now 
consider the various kinds and methods of injection. 



INJECTIONS OF THE EAR. 107 

Injection of the Lachrymal Duct. — This injection may be 
accomplished from above downwards, through the puncta, or from 
beloAV upwards, through the lower orifice of the nasal duct, termi- 
nating beneath the inferior turbinated bone. 

The injection can be thrown through either of the puncta, though 
the inferior one is to be preferred. The operation is thus conducted : 
the patient is seated in a chair, with his head supported upon the 
breast of an assistant ; then the surgeon, with the syringe of Anel 

Fig. 67. 




Ariel's syringe. 

(Fig. 67) held in his right hand, places its point into the orifice of the 
lower punctum, and holds it there a moment lightly, in order to avoid 
producing spasm of the canaliculus, w r hich might occur from its too 
sudden introduction ; he then gently passes it on to the depth of an 
eighth of an inch, when the contents of the syringe must be discharged 
without force, as the fluid ought to reach the sac with ease, if the 
syringe is properly introduced, and there be no obstruction in the 
canaliculus. While the injection is being accomplished, the eyelid 
should be permitted to assume its own position. 

If any trouble is encountered, the introduction of one of Anel's 
probes will be advisable before the syringe is tried again. The injec- 
tion will be required to be made through the superior punctum if the 
inferior is obliterated or obstructed. 

The injection from below is accomplished in the following manner: 
The patient being placed in the same position as in the previous case, 
the surgeon takes one of the catheters of Grensoul in his right hand, 
with its convexity upwards, and its point looking downwards and 
outwards, and passes it into the inferior meatus to the depth of little 
more than an inch, when he should draw ype catheter gently forwards, 
with its beak pressing gently upon the outer wall of the meatus, until 
it is arrested by catching in the inferior orifice of the nasal duct, 
when he suddenly depresses the outer extremity of the instrument. 
The syringe may then be fitted to the catheter, and the injection made. 
When it is necessary to wash the parts beneath the eyelids, a syringe 
with a little bulbous extremity may be had recourse to. 

Injections of the Ear. — For the purpose of cleansing the ex- 
ternal meatus with water, a syringe (Fig. 68) of about the capacity of 
four ounces is commonly used. It is provided with a smooth, slender, 



108 



INJECTIONS. 



cylindrical nozzle, well rounded or bulbous at its point that the deli- 
cate membrane lining that canal may not be injured; at the base of 
the syringe there are two rings, one upon each side, by which the 
instrument is held, the thumb and ring finger being passed through. 
them. Another ring surmounts the piston rod to receive the index 
finger, by the aid of which the syringe is worked. 

Fig. 68. 




Fig. 69. 



Toynbee's syringe and nozzle. 

The fluid to be injected is contained in a basin held beneath the 
patient's ear ; this also serves the purpose of catching the water as it 

runs away from the meatus. To insure 
the clothes of the patient from being wetted, 
it will be desirable to fasten, with a piece 
of wire, beneath the lobule of the ear, a 
tin or pasteboard gutter, which will run 
the water clear from the person (Fig. 69). 

In some inflammatory affections of the 
meatus the parts become exquisitely pain- 
ful and sensitive, so that even with the 
greatest care more or less suffering will be 
inflicted in performing this operation, and 
this results in part from the size and weight 
of the syringe not permitting it to partici- 
pate in the motions of the patient's head 
when he flinches from pain or is disturbed 
in any way. To rid myself of the incon- 
veniences of the syringe, I have long been 
in the habit of using a convenient little 
instrument which consists of a nozzle an inch and a half long with a 
ring fastened to its outer extremity, and connected with the ordinary 
elastic-ball pump. 

The mode of employing it is simply to seize the ring of the nozzle 
between the thumb and index finger of the left hand, and to introduce 
it into the meatus, while the corresponding forearm rests upon the 
top of the patient's head, and maintains it steady. Then with the 
India-rubber ball in the right hand, a stream of water may be continu- 
ously thrown into the meatus and the injection completed without 
removing the nozzle. This is certainly a great advantage, as it is 
well known that not the least painful part of this operation, as ordi- 
narily performed, is the frequent introduction of the syringe, a measure 
absolutely indispensable, in a majority of cases, to obtain a sufficiency 




Toynbee's ear-spout fitted on 
the bead. 



INJECTION OF THE URETHRA. 109 

of water to insure the thorough cleansing of the meatus or the dis- 
lodgment of a foreign body. 

Injection of the Urethra. — Medicated solutions are introduced 
into the urethra by means of the little instrument called the penis- 
syringe ; it is manufactured of glass or metal, the former being pre- 
ferable, as more cleanly and free from the corroding effects of those 
active chemical agents which often enter into the composition of these 
injections. The capacity of the syringe should not be more than one 
ounce, as this quantity of fluid will be amply sufficient to fill the 
entire canal, from the meatus to the bladder. 

In performing the operation the patient may either stand upright 
against a wall or sit upon the edge of the bed or chair, with the peri- 
neum well thrown forwards, that no pressure may be exercised upon it 
so as to prevent the free access of the injection to the deepest part of 
the urethra. The syringe, held in the right hand, may then have its 
nozzle introduced into the meatus, while pressure should be made 
upon the glans with the thumb and index finger of the left hand, to 
sustain it against the shoulder of the instrument, and thereby prevent 
the egress of any of the injected fluid. 

The piston of the syringe must be pressed down slowly, as the 
sudden and forcible entrance of the liquid is apt to excite spasmodic 
action of the canal, and cause a good deal of pain. There is no danger 
of the injection passing into the bladder, as some patients fear, and, in 
their anxiety to prevent it, press upon the perineum during the 
operation. 

Some surgeons recommend that a long curved catheter, with an 
olive-shaped point pierced with small holes, be used in connection 
with the syringe, in order to bring the solution with certainty in con- 
tact with the deeper parts of the urethra; there are diseases of its 
membranous portion which cannot be reached with the penis-syringe, 
and such an instruraent as seen in Fig. 70 is required. The time that 

Fig. 70. 





The catheter-syringe. 

the solution should be permitted to remain in the urethra will depend 
upon its strength; in ordinary cases three or four minutes will geue- 
rally suffice. The operation may be repeated three or four times a day. 
In this manner solutions of the nitrate of silver, sulphates of zinc 
and copper, alum, tannin, and a host of other remedies may be used 
in the treatment of the diseases of the urethra. The usual forms of 
injections will be seen from the following formulae : — 

I£. — Argent, nitratis crystal, gr. x ; 
Aquae f§j. M. ft. inject. 

Used in the abortive treatment of gonorrhoea. (Acton.) 



110 INJECTIONS. 

]£. — Zinci sulpli., 

Acid, tannici, aa gr. ij ; 
Aquae f§ij. M. ft. inject. 

Used in gleet. (Acton.) 

]$. — Ferri proto-iodidi gr. ij ; 

Aquae destillat. f^viij. M. et ft. inject. 

Used in gonorrhoea. (Eicord.) 

$. — Plumbi acetatis 9ij ; 

Aquae rosarum f^v. M. ft. inject. 

Used in gonorrhoea. (Eicord.) 

Injection into the Bladdek. — We have already considered the 
subject of irrigation of the bladder with the double- tubed catheter, and 
but few words are, therefore, necessary under this heading. For the 
introduction of medicated liquids into the bladder, a simple catheter 
is all that is necessary ; this with a small syringe fitted to its orifice 
will enable the practitioner to bring in contact with the vesical mucous 
membrane any medicament he may choose. 

It should be borne in mind that when this organ is inflamed and 
irritable the quantity of the injected fluid should be small, so as not 
to provoke violent contractions, and thereby cause its immediate 
rejection. 

The diseases in which these injections have been used are cystitis 
and calculous affections. Dr. Hoskius, of England, employed the 
saccharate of lead for dissolving phosphatic calculi ; Dr. Eutherford 
used lime-water; Dr. Eitter, caustic potassa; Sir B. Brodie, nitric 
acid ; and other surgeons, simple water, or a solution of bicarbonate of 
soda. None of these trials have, however, as yet, been crowned with 
sufficient success to justify the retention of the plan as a surgical 
resource of any importance. The two following formulas will illus- 
trate the manner in which remedial agents are sometimes combined 
for these purposes : — 

I£. — Argenti nitratis ^ij ; 

Aquae destillat. f§iv. M. ft. inject. 

Used in cystorrhcea. (Acton.) 

$. — Sodae bicarb. £)iijss ; 
Saponis alb. §iss ; 
Aquae destillat. f§iv. M. ft. inject. 

Used in certain calculous diseases. (Bouchardat.) 

Injection of the Ya gin a.— Besides the plan of irrigating the 
vaginal mucous membrane already' described, it is sometimes necessary 
to have recourse to another one, which consists in bringing in contact 
with this membrane solutions of considerable medicinal activity. The 
operation is performed with an instrument called the female syringe, 
which is cylindrical, rounded at its point and perforated with a number 
of small holes, and made either of glass or metal, of a capacity ordi- 
narily of two or three ounces. 

To make the injection, the patient should be placed upon her back, 
with the hips raised upon a pillow and the thighs elevated and 
drawn up; then two or three syringefuls of the fluid ought to be 



INJECTION OF THE UTERUS. Ill 

thrown into the vagina to wash, away any adhering mucosities or 
other discharges, when the third syringeful may be introduced and 
retained there three to five minutes, by means of a napkin pressed 
against the vulva. 

The diseases in which these injections are employed are gonorrhoea, 
leucorrhcea, and various vaginal discharges. 

Professor Simpson has attracted the attention of the profession to 
another valuable mode of applying local remedies to the vaginal mu- 
cous membrane, which consists in the combination of certain remedies 
with lard and wax, and giving them the form of suppositories. They 
bear the name of medicated pessaries. The following formulas will 
indicate the manner in which these are prepared : — 

R. — Zinci oxidi gr. xv ; 

Cerse albaB gr. xv ; 

Axungiae ^fiss. M. f. pess. 
R. — Plumbi acetat. gr. vij ; 

Cerae albse gr. xxij ; 

Axungise 5i ss - M. f. pess. 
R .— Ung. hydrarg. fort, ,53s ; 

Cerse flavae 3ss ; 

Axungiae 5 1 * M» f« pess. 
R . — Plumbi iodidi gr. vj ; 

Cerse flavae 5ss ; 

Axungiae gr. lxx. M. f. pess. 
R. — Tanninae gr. x ; 

Cerae albae gr. xxv ; 

Axungiae ^iss. M. f. pess. 
R. — Extr. belladonuse gr. x; 

Cerse flavse gr. xxiv. 

Axungiae 5i ss - M. f. pess. 

These pessaries are used in various painful and inflammatory dis- 
eases of the vagina and the adjacent organs. (Simpson.) 

R. — Zinci sulpbatis, 

Alumnus calc, aa 5iJ ss » 

Aquae destillat. Oj. M. f. inject. 

Used in leucorrhcea. (Pringle.) 

Injection of the Uterus. — Injections of various fluids into the 
uterine cavity have been performed in some cases with considerable 
advantage, but the operation is a delicate one, and requires circum- 
spection, lest injury imperilling life be done to that viscus. The in- 
strument with which it may be effected is a common syringe, holding 
about an ounce, and mounted with a stem about the size of a ]So. 6 
catheter, and nine inches long. 

The patient may be conveniently placed in the same position as for 
vaginal injection, and the practitioner having introduced his left fore- 
finger up to the os uteri, the stem of the syringe is passed into the 
uterine cavity upon this as a guide. 

The quantity of fluid injected at one time should never exceed an 
ounce, and, in order to be on the safe side, one- half or a quarter of 
this amount may be tried at first. 

In violent uterine hemorrhage it has been recommended to inject 
cold water into that cavity. This can be best accomplished by a 
common straight catheter and the elastic ball pump. 



112 



INJECTIONS, 



Vidal de Cassis employed in several chronic uterine diseases an 
injection of a decoction of the dried leaves of the black walnut. 

Injection of the Kectum, ok Enemata. — When injections are 
made in the rectum they are variously denominated glysters, clysters, 
enemata, or lavements. 

There are numerous forms of the instrument for performing this 
operation : the common enema syringe, now falling into disuse since 
the introduction of India-rubber syringes constructed upon the prin- 
ciple of the force-pump, consists of a white metal cylinder, provided 
with nozzles 4 of different lengths and curvatures, which may be 
attached or detached at pleasure, so as to enable the attendant or 
the patient himself to make the injection either just within the sphinc- 
ter, or to a greater distance up the bowel. This syringe varies in 
size, holding from two to sixteen ounces or more. The inconvenience 
attending the use of this instrument by the patient can readily be 
appreciated, and the great improvement over this of the clyster pumps, 
of which there is an exceeding variety ; but none of them are so sim- 
ple in construction or effective as that manufactured of India-rubber. 
This consists of an oval ball of rubber with two flexible tubes attached 
to it, one at each of its extremities; at the base of each of these there 
is placed a ball valve, opening in the direction of the nozzle. 

The instrument is used by introducing the pipe into the rectum, while 

the other end of the tube is 
Fig- 71. put into a basin ; and then, by 

alternately pressing upon and 
relaxing the hold on the ball, 
the water is sucked up and 
forced into the rectum. 

In hot climates these tubes 
become soft and get out of 
order, so that under these cir- 
cumstances a metallic instru- 
ment is to be preferred ; and 
perhaps the best of this kind is 
that manufactured by Messrs. 
Maw and Son, of London, and 
seen in Fig. 71. 

. Dr. J. Y. Totherick has pro- 
posed an enema tube which he 
believes combines cheapness, 
Metallic ciyster-pump. simplicity, and efficiency in no 

ordinary degree. " The appa- 
ratus consists simply of five or six feet of three-eighths inch India- 
rubber tubing, to one end of which is fixed an ordinary funnel capa- 
ble of holding a sufficient quantity of fluid, and to the other end one 
of the common ivory insertion pipes. The method of using it is as 
follows : first, fill the funnel with the liquid to be employed, whilst 
holding the exit pipe at the same level ; secondly, squeeze with the 
finger and thumb the end of the pipe to which the ivory is attached, 
to prevent premature exit of the fluid ; thirdly, insert the ivory exit 




113 

pipe into the rectum ; fourthly, elevate the funnel to the length of the 
tube, and allow hydrostatic pressure to force in the injection." 

Whichever kind of instrument is employed, it is important that 
their nozzles or pipes be smooth, cylindrical, and well rounded, or 
bulbous at the extremity, in order that the rectal walls be not per- 
forated or torn, an accident which has happened, the fluid being thrown 
into the cavity of the peritoneum, or into the cellular tissue of the 
pelvis, producing in the former case a fatal peritonitis, and in the 
latter tedious and almost always fatal pelvic abscess. 

In administering an enema, the patient may lie upon either, side, 
with the leg which is uppermost somewhat flexed : then, if the old 
form of a syringe is used, having well oiled its nozzle, the surgeon 
gently insinuates his left forefinger, oiled, into the anus, and upon this 
as a director passes the point of the instrument into the rectum. The 
left hand should then hold the head of the syringe firmly and steadily, 
while the piston is being slowly forced down with the right. 

In some cases the great irritability of the gut causes the sphincter 
to contract forcibly ; but no violence should be used to overcome this, 
as the gradual pressure of the pulp of the finger will vanquish the 
resistance in a few moments. 

The curved form of the rectum should always be borne in mind, 
that the proper direction may be given to the syringe in its introduc- 
tion, which should be first upwards towards the umbilicus, then back- 
wards and upwards, after it has penetrated to the depth of an inch, in 
the curve of the sacrum, inclining the nozzle a little to the left. 

As to the quantity of the injection, this will depend upon the object 
in view. If that be simply to evacuate the intestine, the enema should 
be large, twelve to sixteen ounces; and to insure the fluid's remaining 
there a sufficiently long time to soften the fecal matters, it must be 
gradually forced from the syringe, to give the intestine an opportunity 
to adapt itself to the newly -added bulk. From not attending to this 
point an injection may fail in bringing away the fecal contents of the 
rectum, which contracts quickly and strongly under the stimulus of 
a distension suddenly established. On the other hand, when some 
medicament is intended either to exercise a local and continuous action 
upon the mucous membrane, or to affect the system by absorption, 
the quantity should be moderate, from one to three ounces. Thus an 
efficient anodyne is an injection of an ounce of mucilage containing 
twenty or thirty drops of the tincture of opium. 

By reason of the large number of veins about the rectal walls, absorp- 
tion takes place rapidly, and therefore we can obtain a more decided 
impression upon the system in this manner with an equal quantity of 
opium than when it is given in the usual way by the mouth. Cubebs, 
quinia, and other remedies may be administered in the same manner. 

A patient may be kept alive several weeks by nutritive injections 
alone, such as broths, soups, solutions of gelatine, and albumen. But 
none of these articles can supply the absorbents with those elements 
taken up by them from food which has passed through the intestinal 
canal and become thoroughly impregnated with its secretions, so that 
beyond the period stated a person must inevitably perish unless other 
8 



114 INJECTIONS. 

sustenance be introduced into the stomach. It has been suggested 
that the addition of pepsine to these injections may cpntribute in some 
degree to give them the character of digested food. 

Hard lumps of stercoraceous matter or hemorrhoidal tumors may pre- 
vent the fluid from passing into the bowel, or, as O'Byrne has shown, 
feces may collect in the sigmoid flexure of the colon, beyond which 
the ordinary clyster pipe could not throw the injection : in such cases 
as these a long tube, such as is found in connection with the stomach 
pump, must be introduced above the point of obstruction, and the 
enema injected through this. With care a flexible tube two feet long 
can be passed into the colon. 

In constipation, with a relaxed condition of the mucous membrane 
of the bowel, injections of cold water, either alone or with the addition 
of a tablespoonful of common table salt, a little molasses, or a quantity 
of soapsuds, will give great relief to the patient, and suffice to secure 
the discharge of a normal quantity of feces daily. In some cases, 
again, warm water will be found preferable to cold. 

AVhen a powerful action is desired to be exercised, an injection 
containing the oil of turpentine may be had recourse to; such a one 
will be found in the ordinary purgative enema of the Pharmacopoeia. 

In chronic diarrhoea and dysentery, injections of solutions of the 
nitrate of silver, terchloride of iron, and the sulphates of copper and 
zinc may often be advantageously used. 

It should not be forgotten that in employing large enemata the 
rectum may be distended to such a degree as to paralyze its contractile 
power so that the fluid will not be passed until a tube is inserted into 
the anus for that purpose. 

The too frequent use of injections and suppositories may favor, or 
even induce hemorrhoids, or some organic change of the rectum. 

Suppositories are composed of some fatty matter or other adhesive 
material incorporated with any remedial agent. The common purga- 
tive suppository is a piece of brown soap cut into a cylindrical shape 
and of suitable size to be introduced beyond the sphincter ; catharsis 
results from its irritating the lower portion of the rectum. 

If the aim of the practitioner is to introduce a medicament into the 
circulation, it should be reduced to powder and brought to the proper 
consistence with lard or butter, and then moulded into an ovoid mass. 

The suppository can be most conveniently placed in its proper posi- 
tion by means of a small glass syringe, which resembles a penis syringe 
with its nozzle cut olf and the margins of the glass well rounded, so 
that the sphincter may not be wounded. 

The following are common forms of prescription for enemata and 
suppositories : — 

$.— 01. olivse fgj ; 

Magnes. sulph. §ss ; 
Sacchar. alb. §j ; 
Sennse §ss ; 
Aquae bullientis f§xvj. 
Infuse the senna for an hour in the water ; then dissolve the salt and sugar ; add 
the oil, and mix them by agitation. {Ed. Pharm.) 

A laxative enema. 



INJECTION INTO THE CELLULAR TISSUE. 115 

R. — Sodii chloridi ^ss ; 
Adipis 5j ; 
Faecis sacchar. f§j ; 
Aquae fervent. Oj. M. f. enema. 

This is the mild laxative enema of domestic practice. 

R. — Extract, colocyntliid. 3 SS ? 
Saponis mollis £j ; 
Aquae Oj. 
Mix and rub them together. (Lond. Pharm.) 

A powerful purgative injection in colic and constipation. 

R. — Tinct. opii TTi_xxx ; 
Decoct, amyli f^iv. 
Mix them. (Lond. Pharm.) 

This enema is used in strangury, obstinate vomiting, diarrhoea, 
dysentery, and in painful diseases of the kidneys and bladder. 

R. — 01. terebinth. f§j ; 
Vitelli ovi No. j ; 
Decoct, hordei I3XIX. 
Rub the oil with the yelk, and mix the decoction with them. (Lond. Pharm.) 

A stimulating purgative enema. 

R.— Aloes 9ij ; 

Potass, carb. gr. xv; 
Decoct, hordei Oss. 
Mix, and rub them together. (U. S. Pharm.) 

This enema is employed in amenorrhcea attended with constipation, 

and ascarides. 

R. — Assafcetidae prep. £j ; 
Decoct, hordei Oss. 
Rub the assafetida with the decoction gradually added, till they are thoroughly 
mixed. (Lond. Pharm.) 

This is gently laxative, carminative, and antispasmodic. 

R. — Aloes, 

Sodii chloridi. aa gr. xv ; 
Mellis q. s. M. f. suppos. 

An active purgative suppository. 

R. — Pulv. opii gr. f ; 

Butyrei ^ijss. M. f. suppos. 

An anodyne suppository. 

R. — Quinise gr. xv ; 

Butyrei giss. M. f. suppos. 

An antiperiodic suppository when the stomach will not bear the 
quinine. (Boudin.) 

Injection into the Cellular Tissue (hypodermic injection). — 
This is a practice which has only been introduced within the last few 
years, and during that time the repeated experience of the profession 
has sustained it as a very valuable means in the treatment of obsti- 
nate cases of neuralgia and many other painful diseases. The same 
plan has also been suggested for the purpose of bringing in contact 
with the interior structure of tumors, and other morbid growths, 
various irritating and caustic agents, to destroy them either by their 
direct chemical action or the succeeding inflammation. 



116 



INJECTIONS. 



Fig. 72. 



The hypodermic injection is effected with a small syringe of glass 
or gutta percha (Fig. 72), armed with a long, hollow, needle- 
like nozzle for perforating the skin. It is intended to hold 
about one drachm, and the piston-rod is graduated, that the 
dose may be accurately determined. 

The operation is easy ; the practitioner pinches up with 
the fingers of the left hand a fold of the skin, and with his 
right enters the point of the syringe into its base, either by 
a rotatory movement or a quick stab. When the puncture 
is accomplished, the skin must be permitted to resume its 
normal position, when the fluid must be slowly thrown from 
the instrument by pressing down the piston. 

Annoying abscesses in the cellular tissue often succeed to 
this little operation, and is about the only unpleasant acci- 
dent attending it. 

Absorption of the fluid occurs rapidly, and if it contains 
an anodyne in solution, its action is soon manifested upon 
the system by a marked alleviation of the pain. 

The narcotic solution usually employed consists of an 
ounce of water containing a grain of morphia ; of this one 
drachm should be introduced twice a day. The alkaloids 
— aconitine and atropia — may also be employed in solution 
in the doses of one-thirtieth to one-fortieth of a grain. 

It has been proposed to destroy cancerous tumors by 
thrusting the needle of the hypodermic syringe an inch or 
more into their substance, and throw into it thirty to fifty 
minims of dilute acetic acid, one part of the acid to two of 
water. The suggester of this plan, Dr. W. H. Broadbent, 
of London, states that " his aim had been not necrosis of 
malignant tumors, but a modification in their nutrition. 
The theoretical grounds for this hope were, that cancer 
owed its malignancy to its cellular or (to use a nomencla- 
ture now almost antiquated) foetal structure ; and that in 
acetic acid we had an agent which might be expected to 
diffuse itself through the tumor and reach the cells, and, 
having reached them, to effect changes in their structure, 
and affect them vitally, while it could scarcely do harm." 

Injection of Abnoemal Canals. — Long and sinuous 
passages running under the skin and among the deeper 
tissues may often be traced out, and solutions of various 
medicaments brought in contact with their walls. 
The syringe which I employ for this purpose has a capacity of 
about two ounces, is made of glass, and supplied with a number of 
hollow, flexible stems of soft lead eight inches long, and of various 
sizes, each capable of being attached or detached from the syringe at 
pleasure. 

The operation consists in introducing these metallic tubes, bent 
into the proper shape, into the sinus, and injecting the fluid against 
any desired point ; or it may be distributed along the entire course 
of the canal. 



PURIFICATION OF AIR IX HOSPITALS A3 D CHAMBERS. 117 



CHAPTER VI. 

OX THE USE OF GASES AND VAPORS. 

In this chapter it will be our object to consider the various methods 
in which certain vapors and gases are used by the profession as reme- 
dial agents in the cure and prevention of disease. 

Some of these agents are applied to the exterior of the body, either 
to its whole extent or to a limited portion of it. In the first instance 
the operation is called general, and in the latter local fumigation. The 
application of other agents is restricted to the bronchial mucous mem- 
brane, and constitutes what is technically known as inhalation ; while 
a third class embraces those articles which are disseminated in the air 
with a view of purifying it, or destroying any noxious effluvia that 
may be contained therein, and become the cause of disease. When 
these vaporous agents act chemically upon the morbific constituents 
of impure air — that is, destroying them by forming new and inert 
compounds — they receive the name of disinfectants; while those which 
simply mask unpleasant odors are termed deodorants. Of the first 
kind we may mention, as a good type of the whole class, chlorine, 
which disinfects by combining with the hydrogen of sulphuretted 
hydrogen and its compounds ; of the second kind, the vapor of vine- 
gar and eau de cologne diffused through the air of the sick-chamber 
may. be instanced. 

SECTION I. 

PURIFICATION OF THE AIR OF HOSPITALS AND CHAMBERS, OR DISINFECTION. 

The subject of disinfection is one of the greatest importance to the 
medical practitioner, and demands a close investigation as to the real 
extent of its usefulness, and how far it may be relied upon as accom- 
plishing the object for which it is employed. 

There can be no doubt that in a widely-spread epidemic its influ- 
ence is very slight, if at all appreciable, and is far inferior, as a pre- 
ventive means, to other sanitary measures, especially cleanliness. 
Thousands of experiments with the various reputed disinfectants, ex- 
tending over a space of time of more than a century, have been made 
in many parts of the South of Europe in numerous and fatal epidem- 
ics ; and the conclusions from them seem to be, as stated above, that 
little or no reliance can be placed upon this class of agents. 

The atmosphere may be rendered impure by such gases as carbonic 
acid, sulphuretted hydrogen, nitrogen, &c, which analysis makes 
known, and chemistry suggests and supplies the appropriate agents 
to destroy them ; but, unfortunately, in a majorit}' of cases such a 
strictly scientific course cannot be pursued, for the reason that the 



118 ON THE USE OF GASES AND VAPORS. 

presence and nature of most morbific causes diffused in the atmo- 
sphere have as yet remained undiscovered by any chemical tests, how- 
ever delicate. Such, for instance, are the contagious principles of the 
exanthematous fevers, hospital gangrene, and typhus fever; hence, 
the use of disinfectants in such cases is based upon purely empirical 
practice. 

These abnormal elements in the air have been variously termed 
emanations, miasms, malaria, and fomites — names that are simply 
used to designate phenomena of which we are altogether ignorant. 

Some of the simpler cases of atmospheric impurity arise from well- 
determined causes, as a diminution of the natural proportion of oxygen 
in the air surrounding vats where the acetous fermentation is taking- 
place. In this instance, the only remedy is to remove the cause. 
Carbonic acid is largely liberated under the same circumstances, and 
also from plants during the night; it is found in wells and caves 
originating from the decomposition of the surrounding soil. Quick- 
lime and lime-water are the proper corrective agents in these cases, as 
they will absorb carbonic acid to a considerable extent. Dupuytren 
long ago suggested the plan of lighting two fires, one above the other, 
in the mouths of old wells, to displace the carbonic acid by the strong 
current of air thereby produced. The custom of lowering burning 
braziers into wells is based upon the same principle. 

In the neighborhood of sinks and latrines, sulphuretted hydrogen, 
hydrosulphate of ammonia, and nitrogen, are found diffused through 
the air, and may be destroyed by chlorine, or the nitrate of lead 
(Ledoyen's Disinfecting Fluid, composed of eight ounces of the nitrate 
dissolved in a gallon of water), the former decomposing them by ab- 
stracting their hydrogen, and the latter, their sulphur : the resulting 
compound, in the first instance, being chlorohydric acid, and, in the 
second, the sulphide of lead. 

Yarious other disinfectants are sometimes employed with a view of 
decomposing or destroying those atmospheric poisons upon which 
many contagious and epidemic diseases are supposed to depend. As 
stated before, their use in such cases is purely empirical, and their 
asserted efficacy very doubtful. 

Chlorine and its compounds are had recourse to, perhaps offcener 
than any other article, for this purpose. The chlorine may be obtained 
very easily from a mixture containing one ounce of the black oxide 
of manganese, three ounces of common salt, one fluidounce of sulphuric 
acid, and two fluidounces of water. These materials must be placed 
in a saucer or other like vessel ; a number of these saucers thus pre- 
pared may be put at intervals in the wards of a hospital or other 
apartment to be disinfected. The same result may be obtained by 
using the chlorinated lime in dishes, or sprinkling Labarraque's Solu- 
tion — the Liquor Sodse Ghlorinatae of the Pharmacopoeia — upon the 
floor and upon the bedclothes of the patients. In either case a suffi- 
cient quantity of the chlorine should be developed to produce a 
decided odor of that gas, and never enough to cause irritation of the 
bronchial tubes. 

I have employed, as a means of purifying infected ships, a mixed 



PURIFICATION OF AIR IX HOSPITALS AND CHAMBERS. 119 

gas of chlorine and hydrochloric acid, obtained by burning chloroform 
and alcohol together in the proportion of two parts of the former to 
one of the latter. The mixture is placed in a shallow saucer, and a 
piece of cotton cloth immersed in it to serve the purpose of a wick. 
When a lighted candle is applied to a projecting end of the cloth it 
takes fire, and the chloroform burns with a dense black smoke, very 
irritating to the conjunctiva and the bronchia. For this reason it 
could not be used in apartments where the sick are lodged, but for 
purifying empty hospital wards or a ship, nothing can be better 
than this. The plan I usually adopted was to set fire to several 
dishes of the mixture, placed at different points in the apartment, and 
then close up all the windows, doors, and hatches for three or four 
hours. After which everything is again thrown open to permit the 
free circulation of fresh air. 

Chlorine was first employed as a disinfectant in France upon the 
strength of a statement made by the celebrated chemist Guyton de 
Morveau, that it possessed the power of destroying all animal miasms. 
About the same time, Smith, in England, brought forward nitrous 
acid gas as a disinfectant, which shared the great reputation of chlorine 
as an agent for the same purpose. The nitrous acid gas may be ob- 
tained by heating together in a saucer, placed upon a sand-bath, four 
drachms of nitrate of potassa and two fluidrachms of fluoric acid. 

Ozone has also had its share of praise as a purifier of infected air. 
Dr. Moffat, in a paper read before the British Association, in 1862, 
stated that he had employed phosphorus for obtaining ozone, and 
had found it a valuable disinfectant during its luminous state, which 
he discovered to be much influenced by certain atmospheric conditions; 
a high pressure, low temperature, and the wind from the northern 
points of the compass being the conditions of its non-luminosity, and 
the reverse ones those of its luminosity. He describes his plan of 
using phosphorus in the following manner : " I take a quart bottle 
with a wide mouth, into which I put rather more than half a pint of 
water; a piece of cork carrying a flat piece of phosphorus with a 
clean cut surface, floats upon the water. The mouth of the bottle 
is loosely covered with a card. The bottle is then placed first in one 
part, and then in another of the apartment to be purified, until the 
peculiar smell of ozone is detected, or until my test-papers indicate 1 
of my ozone scale. The process of purifying may be performed night 
and morning, or oftener. For purifying air in the neighborhood of 
street gratings or in sewers, I simply suspend a piece of phosphorus 
from the grating. In apartments the temperature may be sufficiently 
high to keep phosphorus luminous under all atmospheric conditions ; 
but in sewers it will be luminous or non-luminous, according to the 
height of the barometer, the temperature of the surrounding air, and 
the direction of the wind, and ozone will be produced only when it is 
luminous." 

The vapor of iodine has been tried in England, with a certain 
amount of success, diffused through the air of the sick chamber. 
According to Eighini it possesses remarkable antiseptic and anti- 
spasmodic properties, and is a valuable hygienic resource in hospitals. 



120 ON THE USE OF GASES AND VAPORS. 

He recommends that it be employed in the following manner : A soft 
paste is made by moderately heating sixteen parts of starch in a 
sufficient quantity of distilled water, and stirring them with a wooden 
spatula. Eight parts of iodoform having been added, the mixture 
will be found to be readily absorbed by filtering-paper. The paper 
prepared in this way is cut into strips three or four inches wide, and 
suspended in the wards. The iodoform slowly escapes without causing 
any inconvenience to the inmates. It is most freely liberated in moist 
states of the atmosphere. M. Kighini recommends iodoform paper 
for the purpose of obviating the bad smells and noxious effluvia of 
slaughter houses, and also for preserving meat from spoiling. 

Sir William Burnet's disinfecting fluid is a solution of the chloride 
of zinc in water, in the proportion of twenty-five grains to one fluid- 
ounce. In using it, one pint of the fluid may be mixed with five gal- 
lons of water. Its power is limited to the decomposition of sulphu- 
retted hydrogen and hydrosulphate of ammonia. 

The permanganate of potassa is a valuable disinfectant, acting by 
decomposing the noxious gases; it is itself insipid and inodorous, 
which is a further commendation of this truly efficient agent in 
surgical practice. It may be employed either in solution or in powder 
mixed with starch or carbonate of lime; a few applications of the 
remedy to grayish-colored and fetid ulcers, or gangrenous wounds, 
will entirely remove the bad smell and restore a roseate color to the 
diseased tissues. Injections of the permanganate may be made in 
cancerous affections of the uterus, and in chronic ulcerations of the 
mucous membrane of the nasal fossae, with advantage. 

Sulphurous acid gas was very anciently employed as a disinfectant, 
and is mentioned by Homer. It may be obtained by burning sulphur 
in an open vessel, or by applying heat to a mixture of mercury and 
sulphuric acid contained in a retort. MM. Kurz and Manuel recom- 
mended that the streets of Paris should be fumigated with the 
sulphurous acid gas during a malignant and widely spread epidemic 
of cholera. 

The bisulphite of soda and the sulphite of soda and lime enjoy similar 
properties with the sulphurous acid. 

Cheap disinfectants for throwing into latrines and for covering up 
masses of decaying animal and vegetable matters, will be found in 
common quicklime, and the powder of MM. Corne and Demeau, 
which consists of 100 parts of sulphate of lime and three parts of 
coal-tar. 

Carbon, in the form of smoke, is often used by sailors to disinfect 
ships ; its efficacy is materially enhanced by the presence of a small 
quantity of creasote, which is always present among the products of 
the combustion of wood. 

We cannot properly consider the explosion of gunpowder and the 
making of large fires in infected localities as possessing disinfecting 
properties. They can act in no other way than by causing a move- 
ment or circulation of the air, from which little assistance could be 
expected under any other circumstances than dislodging carbonic 



PURIFICATION OF AIR IN HOSPITALS OR CHAMBERS. 121 

acid or other gaseous agents from wells or excavations. M. Balcels, 
a chemist of Barcelona, suggested that cinnabar and the oxide of 
arsenic be added to the gunpowder before explosion. 

The vapors of vinegar, acetic acid, camphor, and the resins should 
rather be regarded as deodorants than as disinfectants. 

For the purpose of purifying the garments of the sick, the Hebrews 
depended largely upon the copious use of fresh water, and doubtless 
this agent, unassisted, will suffice in many cases ; but the operation 
will be very much more certain and speedy in all cases by the use 
of steam at 200° or even higher. Dry heat will answer the same 
purpose, but it is apt to damage the texture of the clothes. 

When water is employed in cleansing infected wearing-apparel and 
bedclothes, the addition to it of lime-water or the solutions of the 
bisulphite or hypochlorite of soda will facilitate the acquisition of the 
object in view. 

M. Balcels had recourse first to a solution of the pernitrate of mer- 
cury in water, in the proportion of one part of the former to seventy 
parts of the latter, and then fumigated the clothes with chlorohydric 
acid gas. 

Disinfection naturally includes the action of antiseptics, and the 
latter, therefore, need a passing notice. The antiseptic most frequently 
employed in hospital gangrene and sloughing sores or wounds is the 
permanganate of potassa in solution, in the proportion of five parts to 
fifteen parts of water. 

A piece of fine linen wrung out of a solution of the chloride of 
soda (Labarraque's solution), and "laid over the parts, will correct the 
fetor of profusely suppurating wounds. 

Bromine has been much used, of late, for the purpose of arresting 
the progress of hospital gangrene, and is considered an effective agent. 
It may be applied with a camel's-hair brush. 

Carbolic acid, an oily liquid obtained by distilling coal tar and 
quicklime together, resembles creasote in its antiseptic properties, 
contracting and hardening the animal tissues, and protecting them 
from putrefaction. 

A concentrated solution of the bisulphite of soda, injected into the 
arteries, will preserve a subject from decomposition six or eight weeks 
in the warmest weather. 

Ammonia, in the form of vapor, possesses antiseptic power to a 
considerable extent ; it acts catalytically, by preventing oxygen com- 
bining with oxidizable matters. In employing this agent for the 
preservation of organic substances, it is important to exclude all other 
antiseptics before or during the time the specimen is being exposed 
to the vapor. The only apparatus needed is a simple jar, in which 
the substance to be preserved is suspended, having previously intro- 
duced into it about a drachm of strong liquid ammonia ; then render 
the jar hermetical by a luting of soap or a mixture of soap and red 
lead. For the preservation of fluids, ammonia may be added to them 
in the proportion of ten to twenty minims to the ounce. 

Cleanliness, both of the apartments and the clothes and person of 



122 ON THE Us E OF GASES AND VAPORS. 

the sick, will do more towards preventing the rise and progress of 
disease than any amount of disinfection. 

The rooms in which the sick and wounded are lodged should be 
scrupulously cleansed; the floors well scrubbed, but never flooded 
with water, as is sometimes done, particularly in the "sick bays" of 
our men-of-war. The simplest plan to avoid this is "dry scrubbing," 
which consists in using a brush and sand only, and subsequently 
sweeping the floor with a broom ; or, again, the scrubber may use a 
brush and hot water, drying apace as he proceeds. The walls should be 
covered with whitewash, which, though it may not act as an absorbent 
of pernicious miasms, as some have supposed, will, nevertheless, be 
advantageous by keeping them clean, and diffusing around a feeling 
of cheerfulness. 

All vessels containing slops, soiled dressings, and offensive dis- 
charges ought to be removed at once from the room, and a free circu- 
lation of air kept up in it. This maybe accomplished by opening the 
windows and doors in summer; in winter, a fire built in the chimney- 
place will cause a current from the crevices of the doors towards the 
fire and up the chimney. 

On board of ships, ventilation is a matter of the greatest moment 
to the health of the crew, who are usually crowded during the night 
into a very restricted space; and were it not for the numerous hatches 
almost always kept open, serious consequences to the health of the 
men would certainly result. In the construction of the English hos- 
pitals and barracks, 1200 cubic feet of breathing space is allotted each 
man, which is far greater than the allowance in our war vessels, aboard 
of which, by an injudicious system of bulkheads, but one person, the 
captain, of the whole complement has, during sleep, a sufficiency of 
that health-sustaining element, pure air. 

For the purpose of ventilating the apartments below decks, air- 
chimneys, or windsails, as they are called, are used, and sometimes 
specially constructed machines, such as the ventilators of Hales, Brin- 
dejonc, and Souchou. 

The figure from Fonssagrive (Traite Hygiene Navale) shows the ven- 
tilator of Brindejonc (which is one of the best), by which the foul air 
of apartments either in hospitals or in ships, may be driven out. It 
consists of a cylinder 25 inches in height, having two parallel bases 
of 3 feet 3 inches in diameter. One of these bases is provided with 
a toothed wheel of 12 inches in diameter, having fifty-two teeth, and 
supporting at its centre a crank; this wheel turns, when it is in 
motion, a little cog armed with thirteen teeth, and to the centre of 
which is fixed a stem with the four wings of the ventilator. The 
other base has at its middle a circular opening of 11 inches, traversed 
diametrically by a small iron bar which is used as a point oVappui to 
the axis. Upon one of the points of the circumference of the cylinder 
there is an elliptical opening, having 19J inches in its transverse dia- 
meter, and 11 inches in its vertical axis, through which the air comes 
out. The ventilator is arranged with four wings, cutting each other 
at right angles. When the toothed wheel is put in motion by the 
crank, it catches upon the little pinion, and turns the wings rapidly; 



APPLICATION OF VAPOKS AND GASES TO SKIN. 123 

the air is introduced through the circular opening at the base, and 
issues forcibly from the elliptical opening upon the side of the 
cylinder. 

Fig. 73. 




Brindej one's ventilator. 

In connecting the machine with the air of apartments and that 
externally, we employ stiff cylindrical pipes made of canvas, and of 
the necessary length. 

With a small five-horse power steam-engine, 25,000 cubic feet of 
fresh air, heated to an appropriate temperature, can be driven per 
minute through the wards of the largest hospital, and in all our steam 
war vessels this plan should be adopted, particularly in those cruising 
in hot latitudes. It has been found efficient in the iron-clads, and 
quite as great a necessity exists for a good system of ventilation in 
other classes of vessels. 

SECTION II. 

THE APPLICATION OF VAPORS AND GASES TO THE SKIN. 

1. Fumigation. — We have already described the manner of apply- 
ing aqueous vapor to the skin, under the heading of vapor bath, and 
we have, therefore, nothing further to say of it in this place. 

Other vapors are also used, either dry or moist ; their action, like 
the aqueous vapor, partly depends upon their heat, humidity, and 
density, but in general they also possess some special therapeutical 
activity, either locally or being absorbed generally ; in the latter case 
the whole system is more or less influenced by them. Thus the vapor 
of water may be rendered more emollient by the addition of some bland 
substances, such as marshmallow; or, what is more often the case, 
stimulating and alterative by combining it with the vapors of alcohol 
or the mineral acids. Sulphur, the volatile oils, camphor, benzoic 
acid, the resins, and gum resins are volatilized by throwing them upon 
hot metallic plates placed beneath an apparatus by which the patient is 



124 ON THE USE OF GASES AND VAPORS. 

surrounded; they have an action similar to that of the preceding 
medicaments. 

Of the articles absorbed into the circulation, the most frequently 
employed are the compounds of mercury, and their use by fumigation 
in the East Indies dates back to a very remote period. They are 
still much used by the native practitioners in the treatment of obsti- 
nate skin diseases and syphilis. In skin disease, the quantity of the 
sulphide of mercury, of cinnabar, of black oxide, or of the common 
mercurial ointment employed at one fumigation, is from a half to three 
drachms, and of sulphur half an ounce volatilized upon a hot iron 
plate placed beneath a blanket supported on hoops and surrounding 
the patient's person. If he is out of bed, a common box or hogshead, 
with a hole cut into it for the head to be protruded that the vapors 
may not be breathed, will answer the same purpose. 

A higher temperature of a dry gas may be more easily borne than 
a lower one of a humid gas, for in the latter case the transpiration 
will be arrested, and the patient will, therefore, suffer greatly from a 
sensation of internal heat and oppression, and soon become exhausted. 
The difference in the action of moist and dry gas is shown in the 
experiments of Drs. Fordyce and Blagden upon heated air, by which 
it was demonstrated that a man might remain some time in an oven 
with a dry air heated to 350° ; while air of the same temperature con- 
taining aqueous vapor could not be borne. 

The classes of cases in which fumigation is employed are chronic 
rheumatisms, syphilitic affections, and inveterate skin diseases. 

Sometimes the application of the vapor is limited to restricted por- 
tions of the body by means of boxes of a sufficient size to surround 
them. In this way, chronic inflammations of the joints, periostitis, 
and ulcers have been treated. M. Dumarquay has succeeded in re- 
lieving pain, in checking fetid secretions, and sometimes in healing 
ulcers, by surrounding the parts with an atmosphere of carbonic acid. 

2. The Application of Hot Air to Wounds. — M. Jules Guyot 
suggested the unique method of treating wounds by immersing them 
in an atmosphere of heated air, and which he designated as the method 
of curing wounds by "incubation" (par incubation). The plan is 
founded upon the observations of surgeons in hot climates, that wounds 
healed more quickly under an elevated temperature than the reverse. 
This is strikingly illustrated in the influence of our high summer heats 
over the adhesive process, which takes place much more surely than 
in cold weather and damp cool latitudes. The same thing is observed 
in the constitution of the Arab, whose climate, active habits, and diet 
produce a spare and sinewy frame and a sort of dry temperament very 
favorable for the quick healing of wounds. I have made the same 
observation in some parts of the East Indies where the population is 
under analogous influences. In the Gulf of Mexico the heat during 
the summer is excessive ; and it was during a period of this sort of 
weather that I received into the hospital under my charge, at the 
mouth of the Mississippi River, a large number of the wounded during 
the naval operations against New Orleans. Though the buildings 
were crowded with the wounded and fever patients, all of the wounds 



APPLICATION OF HOT AIR TO WOUNDS. 125 

healed with unusual rapidity ; and of fifteen cases of amputation of the 
thigh and arm but two died, both of them after secondary operations, 
one of the patients having lost a good deal of blood from having his 
knee shattered by -a rifle shot ; in the other case, disarticulation was 
performed at the shoulder for a gunshot wound of both the axillary 
artery and vein. 

Kochard, in speaking of the healing of wounds in hot climates, 
says : "All of our confreres point out the rapidity of their course and 
the promptitude with which they heal. I have myself been able to 
verify it often at Madagascar. The bad guns of which the Sacolares 
made use often burst in their hands, and I have seen some of these 
complicated wounds, for which I had proposed amputation, heal with 
a wonderful facility, in spite of the most irrational treatment. Inter- 
tropical climates are favorable to the efforts of conservative surgery ; 
and operations, when it is impossible to avoid them, succeed better 
there than in Europe. The same observation has been made in 
Oceanica, on the coast of Africa, in South America, and in the Antilles. 
It explains the almost constant success of the amputations of naval 
surgeons on equatorial stations, and the remarkable cures that they 
often obtain when it is possible to abstain from them." 

The incubative apparatus of Guyot was invented for the purpose of 
placing wounds under these identical conditions as found in hot 
climates. It consists of an oblong box about fourteen inches long, 
twelve inches deep, and twelve inches wide, with its extremities open, 
and having tacked around the margins of each a piece of muslin a 
foot wide, and furnished at its unattached border with an elastic cord 
to closely embrace the limb. The lower wall of the box is double, 
the upper partition dividing the box into two parts, an upper and 
larger one and a lower one ; these communicate with each other by 
means of two narrow grooves in the lateral walls of the box, while the 
smaller compartment is connected with the external air by means of 
an elbow- tube, under the external extremity of which, shaped like a 
funnel, a spirit lamp is to be placed. The upper wall of the box must 
be a glass plate, that the condition of the inclosed limb may be always 
under observation ; and the bulb of a small thermometer is placed 
inside the box, with its stem projecting exteriorly, so that the tempera- 
ture of the inclosed air can be ascertained at any moment. 

The apparatus above described is that directed for wounds of the 
lower extremities ; but Guyot proposes a number of others, constructed 
upon the same principle, to be used for the arms, shoulder, hip, and 
even for the whole body. 

The wounded part must be inclosed in the apparatus in such a 
manner that the movements of the patient or the involuntary contrac- 
tions of the muscles may not disturb it, or, if it be a stump, pull it 
from the box. 

Guyot, in his practice, sustained the air within the box at about 
81° Fahr. M. Robert employed the apparatus extensively in the 
treatment of wounds, ulcers, and a large number of surgical diseases ; 
and advised that in recent injuries a period of twelve hours should be 
permitted to elapse before applying it. 



126 ON THE USE OF GASES AND VAPOES. 

Velpeau states that he has made some trials with the apparatus in 
his department in the hospital of La Charity but they have been 
neither sufficiently numerous nor varied to allow of his giving an 
opinion of its value. 

SECTION III. 

THE APPLICATION OF GASES, VAPORS, AND ATOMIZED LIQUIDS TO THE 
INTERIOR CAVITIES. 

, Inhalation. — The simplest method of influencing the bronchial 
mucous membrane by vaporous remedial agents is to diffuse them 
through the atmosphere of the patient's apartment ; in this manner we 
use burning tar and paper saturated with a solution of the nitrate of 
potassa. It has been proposed to conjoin some of the narcotics with 
the nitrate of potassa — for instance, belladonna, stramonium, digitalis, 
and lobelia ; the materials may be mixed with paper pulp, and moulded 
into pieces of suitable size, one of which may be burnt in the chamber 
of a patient, in the evening, during an asthmatic paroxysm. 

Some, again, prefer to smoke the dried leaves of the stramonium 
plant in a pipe, or to have them cut fine and rolled up in imitation of 
cigarettes. The following formula 'will show how the cigarettes may 
be prepared : — 

R> — Fol. belladonnse gr. iv ; 
Fol. stramonii, 
Fol. hyoscyami, aa gr. ij ; 
Fol. phellandrii gr. jss ; 
Extr. opii gr. J ; 
Aquae lauro-ceraci q. s. 
Dissolve the extract of opium in the cherry-laurel water, and, having cut the leaves 
fine, mix them with the solution, and roll them up in paper also previously moistened 
with the laurel- water and dried. (Jamain.) 

Two or three of these cigarettes may be smoked each day during 
an attack of nervous asthma. 

Easpail recommends the inhalation of the vapor of camphor, small 
fragments of which may be placed in a quill for that purpose ; it is 
vaporized by the warmth of the palm of the hand in which it is held. 
He says it relieves catarrh, obstinate cough, and the paroxysms of 
asthma. 

Special instruments, called inhalers, are sometimes employed for 
this purpose, an old form of which is that designated as the Mudge 
inhaler, consisting of a pewter pot with a cover to which a flexible 
tube and mouthpiece are attached ; but a more useful and convenient 
inhaler may be easily prepared in the following manner : Get of any 
tinner a cylindrical tin vessel about ten inches high and three and a 
half to four inches in diameter ; inside of this have another tin vessel, 
half the length of the former, fitted and resting upon its edge by a 
narrow rim ; three-quarters of an inch from its bottom there is a pro- 
jecting ledge to support a double tubulated glass jar to contain the 
fluid to be inhaled. One of the tubulures is fitted with a cork support- 
ing a glass tube to permit the entrance of air to the jar, and a slim 
thermometer to indicate the temperature of its interior ; to the other 



INHALATION 



127 



Fig. 74. 



Fig. 75. 




Inhalers. 



tubulure a flexible tube and mouthpiece are attached, through which the 
patient inhales the vapor from the interior of the jar. The inner tin 
vessel contains water, and serves the purpose of a water bath, being 
heated by a spirit-lamp placed beneath it, through a large aperture 
cut into the outer vessel near its bottom. With this simple inhaler 
any volatile substance dissolved in water, and placed within the glass 
jar, may be brought in contact with the bronchial mucous membrane. 

A still less expensive inhaler may be prepared, represented in Figs. 
74, 75. It consists of a wide- mouth 
jar fitted with a cork, through which 
two glass tubes pass to the interior 
of the vessel. Through the bent 
tube the patient inhales the vapor 
rising from the liquid in the jar, 
while the other tube, projecting be- 
low the fluid, admits the air from 
the exterior. 

By the addition of geum, marsh- 
mallow, slippery-elm bark, elder 
flowers, &c, to the water, emollient 
vapors are obtained, which are very 
soothing to the irritated bronchial 
tubes; a few drops of any of the 
volatile oils, or tincture of guaiacum, 
render the vapor stimulating, while opium, belladonna, and hyoscya- 
mus confer calmative properties. 

A simple plan of inhalation, often employed in domestic practice, 
is to reverse a funnel over the vessel containing the liquid, and 
through its smaller end the patient draws the vapor, by placing it in 
his mouth and making deep inspirations. M. Eighini states that the 
inhalation of iodoform dissolved in ether is of great service in retard- 
ing the progress of phthisis. 

A teaspoonful of chlorine water to a pint and a half of water, placed 
in the inhaler and respired three or four times a day, according to the 
tolerance of the patient, once enjoyed a high reputation in the treat- 
ment of phthisis and other pulmonary diseases. Sir Charles Scuda- 
more used, as he thought with advantage, in similar cases, the vapor of 
iodine. Indeed, the whole class of volatile medicines has been tried 
from time to time in the treatment of the various affections of the 
lungs, sometimes with advantage, and at others fruitlessly. 

The idea of inhaling oxygen was long ago spoken of by Sir Hum- 
phrey Davy, and. in 1804 Dr. Eddoes had conceived the propriety and 
utility of the same method of medication. Dr. K. H. Goolden, of 
London, has made some experiments lately with this agent, and adds 
his testimony to its advantages in phagedenic ulceration of the throat 
and in chronic gout. He employed a large vulcanite bag, with a tube, 
stopcock, and mouthpiece, which was filled with a mixture of oxygen 
and air in the proportion of one to four. The gas is inhaled by the 
patient and expired into the atmosphere. The administration may 



128 



ON THE USE OF GASES AND VAPORS 



be made for half an hour each day, the gas being slowly inspired at 
intervals, and filling the lungs as much as possible. 

Inhalation of Atomized Fluids. — More recently, a new method 
of inhalation has been introduced into practice, that of employing 
atomized remedial agents in the treatment of thoracic diseases. 
It consists in substituting for vapor solutions of certain substances 
in a finely-divided state, forming a mist or spray. This novel plan 
was first suggested by Sales- Grirons, in 1852, and since that time has 
been employed by physicians both in Europe and America with decided 
success in relieving and curing many of the diseases of the throat and 
lungs. In fact the whole system may be affected by these inhalations, 
as sea-water used in this manner seems to exercise a decidedly bene- 
ficial influence on scrofula, particularly as it occurs in young subjects 
under bad hygienic influences in large cities. 

The instrument by which the fluid is converted into spray is called 
an atomizer, the simplest form of which is seen in the common nur- 
sery tube, which consists simply of two glass tubes placed at right 
angles, and having their approximating ends drawn out in small 
orifices ; the tubes are supported in the above position by a metallic 
brace. In using the instrument one of its legs is immersed in fluid, 
and the person blows forcibly through the other, by which operation 

Fig. 76. 







Atomizer of Sales-Girons 



the rapid passage of the air through the horizontal tube over the open 
orifice of the vertical tube produces in the latter a vacuum which the 



INHALATION OF ATOMIZED FLUIDS. 



129 



fluid in the cup rises to fill, and finally emerges at the orifice into 
the stream of air, and is there broken up by it into spray, and pro- 
jected from the instrument some distance, according to the strength 
of the current of air. 

As the operation performed in this manner would be objectionable, 
both on account of the fatigue it would be to the operator as well as 
the repugnance the patient would have to breathing air projected 
directly from another person's lungs, the elastic force of compressed 
air or of steam is employed for this purpose, and hence the use of 
two kinds of instruments. Of those in which a rapid current of com- 
pressed air is used, the instrument (Fig. 76) invented by M. Sales- 
Girons is the best, and, though somewhat complicated, yet it works 
beautifully. It consists of a glass jar, A, containing an air-pump, which 
exercises the requisite degree of pressure upon the fluid contained in 
the jar ; c is the manometer for indicating the degree of compression ; 
D is the tube through which the fluid escapes to pass to the drum G, 
inside of which there is a little metallic disk, placed obliquely, upon 
which the fluid strikes, to be atomized and then thrown by the drum 
towards the face of the patient; an elastic tube is put below the drum 
with an expanded end above to catch the drops of fluid which escape 
from the drum, and to carry them into the glass below. 

The steam Atomizer, Fig. 77, consists of a small copper boiler with 
a rectangular tube attached to it, and furnished with an aperture at the 
top through which the water for making steam is introduced ; this is 



Fig. 77. 



Fig. 78. 








Steam atomizer. 

closed with a common cork. Along side of this is a small steam valve 
designed to permit the escape of steam when the interior pressure rises 
beyond a certain degree. A small glass or porcelain cup is intended 
to hold the fluid to be atomized, and is placed so that the vertical tube 
may be immersed in it. To employ the instrument, place a spirit 
lamp beneath the boiler containing water, and when the steam begins 
to flow through the horizontal tube, the little cup with its contents 
must be put beneath the vertical limb, and immediately the liquid 



130 



ON THE USE OF GASES AND VAPORS 



will rise in the tube and become atomized in the current of steam. 
Fig. 78 shows the shield to protect the face from the vapor. 

With the atomizer any substance capable of solution may be intro- 
duced into the lungs in the form of a spray. As an illustrative example 

we may employ carbolic or phe- 
Fi g- 79. n i c acid, suggested some three 

years since by that eminent phy- 
siologist Dr. Longet in tubercu- 
losis, of which he himself was a 
subject. The mode of admini- 
stration is as follows: fifteen 
drops of pure acid are dissolved 
in 3ij of alcohol, and the solu- 
tion mixed with 3xij of water. 
This quantity may be atomized 
and inhaled daily. 

Besides the bronchial mucous 
membrane it is proposed also to 
bring the spray in contact with 
the lining membranes of the 
bladder, the vagina, and the ute- 
rus with specially constructed 
instruments. 

M. Dumarquay, in his work 
on pneumatology, extols the ad- 
vantages of the introduction of 
carbonic acid gas into the blad- 
der in diseases of the genito- 
urinary organs, such as cystitis 
and vesical neuralgia. The vesi- 
cal douche may be easily ad- 
ministered with a small caoutchouc bag filled with carbonic acid, 
which is thrown into the bladder through a common catheter; or 
Mondollot's apparatus may be employed, consisting of a double-tubed 
catheter and an India-rubber bag, which facilitates the escape of any 
gas in excess in the bladder. 

The same author has also derived benefit from the carbonic acid 
douche in certain uterine affections — a.menorrhcea, dysmenorrhea, 
chronic enlargements, and simple ulcerations of the cervix. 

It may be effected with the apparatus seen in Fig. 79, which con- 
sists of a common bottle having attached to its mouth an elastic tube 
about three feet long, provided with an ivory nozzle. 

The materials to be introduced into the bottle for generating the 
gas are about a tablespoonful each of bicarbonate of soda and tartaric 
acid with six ounces of water. 




Apparatus for applying carbonic acid gas to the 
uterus. 



PREPARATION AND APPLICATION" OF BANDAGES. 131 






CHAPTER VII. 

THE -SECOND PIECES" OF DRESSING. OR BANDAGES PROPERLY 

SO CALLED. 

\Ye have already described the " first pieces" of surgical dressings, 
those which are intended for immediate contact with wounds. Some- 
times they .are the only dressings employed in the treatment of a 
case, but more frequently other pieces are required to retain them 
in a proper position ; and it is to these that the technical term " second 
pieces"' has been applied, or simply bandages. 

Bandages are of three kinds, simple, compound, and mechanical. 
Simple bandages are formed by an entire roller arranged with various 
convolutions, and in different manners, and receiving distinctive names 
according to these differences. Compound bandages consist of two 
or more pieces of a simple bandage, either separate or sewed together 
in diverse manners. Mechanical bandages are more complex, and 
are generally formed of wood, metallic plates, levers, &c. ; they are 
also designated as machines, apparatus, or mechanisms, and are prin- 
cipally employed in the treatment of fractures, dislocations, and dis- 
tortions. 

SECTION I. 

GENERAL RULES FOR THE PREPARATION AND APPLICATION OF BANDAGES. 

There are certain general rules which control the preparation and 
application of all bandages, and these will therefore require a general 
notice. 

In the first place, all the pieces of a bandage to be applied should 
be brought together, and be at hand for immediate use, so that the 
dressing may not be delayed, after it is a third or half finished, for 
the want of some necessary article which has been overlooked or mis- 
laid. The necessities of each case ought to be carefully investigated 
before the bandaging commences, otherwise it may be found that it will 
not answer all the indications presented, and thus not only will time 
be lost, but much unnecessary pain be inflicted upon the patient. Yet 
it does happen, in some cases of fracture, that the first apparatus will 
have to be changed or much modified before the patient feels free 
from pain ; and it should never be forgotten that a bandage, caus- 
ing continuous pain or uneasiness, inflicts more injury than can be 
counterbalanced by any good it may confer. Under these circum- 
stances the patient would do better were he abandoned to his own 
ingenuity and the dictates of his own sensations. 

All crowding around an injured person should be avoided, and only 
such assistants as the surgeon may deem necessary to aid him in the 



132 SECOND PIECES OF DRESSING, OR BANDAGES. 

accomplishment of his object should participate in the dressing. Their 
duties will be to supply promptly, as called for, the various articles 
that are wanted ; to support the patient's limbs after he has been 
placed in an easy and convenient posture, and to raise him from the 
bed, or to shift his position as the surgeon may desire, and to maintain 
splints or other apparatus in their proper situation until properly 
secured. Each person assisting should have his duties assigned him 
before the operation begins, and under no circumstances should he 
depart from them, unless ordered to do so by the surgeon. 

The bandage, in order to be effective, must be applied with regu- 
larity, that the pressure may be uniform everywhere ; and a no less 
important precept is, to have such an amount of that pressure as the 
case demands, otherwise if the bandage is too loose, it will slip, and 
the object, therefore, will not be obtained ; or, on the other hand, if 
too tight, the most deplorable consequences may ensue, as mortifica- 
tion of the parts compressed. The greatest attention should be paid 
to the bandaging of recent injuries before inflammatory swelling has 
occurred, and of fractures where we employ the immovable apparatus. 

That the blood may not be arrested in the lower parts of the limbs, 
and give rise to congestion, oedema, or even gangrene, the bandage 
ought to be applied first to their distal extremities, and made to ascend 
gradually towards the trunk. 

As to the material of which bandages should be fabricated, linen 
cloth is. far preferable to any other ; but from its high price, and the 
near approach to it in all useful qualities of cotton cloth, the latter is 
now most generally used. 

Yelpeau remarks of woollen cloth "that it would often be preferred 
to linen for bandages if it were less dear. Though we might for this 
purpose make use of any kind of woollen cloth, or stuff, we generally 
prefer flannel, and that almost exclusively, for woollen bandages. 
Pliable, porous, and resistant at the same time, flannel bandages have 
the advantage of adapting themselves exactly to the parts, and with 
very little tendency to become displaced, or to plait or roll up upon 
themselves ; they also increase the temperature of the part, and readily 
absorb excreted fluids ; they are very extensively used in England. 
There is, however, the objection, that they keep up a certain degree 
of irritation upon the skin, uselessly heat the parts, and soon become 
badly soiled ; neither do they answer as well for the establishment of 
reverses as linen bandages, and are, besides, too distensible, and of a 
kind that cannot be readily had on all occasions." 

Caoutchouc and gum-elastic bandages have also been used, and 
praised for their elasticity and the equability of their pressure ; but 
these desirable qualities are more than counterbalanced by their 
impermeability to the cutaneous transpiration, and the difficulty of 
regulating the degree of pressure, as well as their expense and inac- 
cessibility under ordinary circumstances ; and for these reasons they 
have not come into general use. 

Cambric and calico have also had their admirers, but they are 
objectionable for bandages, when new, because of the glazing, which 
readily permits the turns of the roller to slip ; and when the sizing is 



PREPARATION AND APPLICATION OF BANDAGES. 133 

washed out, the material becomes thin and yielding, and rolls up in 
cords with extreme facility. 

As the roller-bandage is an important element in very many sur- 
gical dressings it demands a special notice. The cotton cloth of which 
it is made should be of medium thickness, bleached, soft, and new ; 
washing destroys to some extent its elasticity. It is torn into strips, 
from one to three inches wide, and from one to ten yards long, 
in the direction of the warp of the stuff. It is always desirable to 
have each roller in one piece, but in case of necessity a number may 
be tacked together in such a manner that their lines of junction may 
not produce wheals or excoriations. This may be avoided by over- 
lapping the ends of two pieces for an inch, and fastening them together 
by what the sempstress calls the cat-stitch, which will place the threads 
upon the outer surface of the bandage, or they may be sewed together 
by a running stitch, and each end afterwards doubled back upon itself 
and secured by the cat-stitch; in this way both the stitches and the 
free ends will be upon the outside. The selvage should be removed 
from the edges of the strips ; as it yields less than the balance of the 
cloth, the skin may be injured by its pressure. To prevent the 
threads from ravelling, it has been suggested to whip-stitch the edges 
of the strips, but it is far better to avoid this, as all the loose threads 
may be effectually torn away from the ends of the roller with the 
fingers. 

In Germany, long, loose, light, and elastic strips are woven for sur- 
gical use, with a single horse-hair running along each edge under little 
loops, which is to be removed when the rollers are used ; by means of 
the little loops the edges of the band yield equally with the balance 
of the material. 

Strips are rolled up for the purpose of enabling the surgeon to apply 
them with rapidity and neatness. The rollers should be moderately 
firm and of a convenient size, so that the strip shall never be more 
than eight or ten yards long. A large roller is apt to slip from the 
hand and to interfere with the neat adjustment of the bandage. 
One is more likely to apply a roller too tight when it is hard than 
when it is in the contrary condition. 

In ordinary cases the surgeon prepares the roller with his hands ; 
while in hospitals, where large quantities of bandages are consumed, 
a little instrument called the bandage-roller is commonly employed. 

To put up a roller with the fingers, select a strip of the proper 
length and width and double one end of it upon itself for eight or ten 
inches; repeat the operation with the doubled portion a number of 
times, until a small cylinder is formed, which should then be taken in 
the thumb and first two fingers of each hand and rolled upon itself 
until it assumes sufficient thickness to bear some pressure, when the 
cylinder must be held between the thumb and the second and third 
fingers of the right hand, that side of it facing the surgeon to which 
the free portion is tangent, and the unwound part between the radial 
border of the left hand and thumb ; the last three fingers of this hand 
are extended under the cylinder, and by their pressure and the alter- 
nate supination and pronation of the left hand it is made to revolve 



134 



SECOND PIECES OF DKESSING, OE BANDAGES. 



rapidly (Fig. 80). Should the hand supporting and tightening the 
wound portion of the bandage become fatigued, the other hand must 

Fig. 80. 




Mode of making a roller bandage. 

be made to relieve it. At any time during the rolling, the turns upon 
the cylinder may be drawn firmer by simply holding it by its ends 
between the forefinger and thumb of the right hand, while strong 
traction is made upon the free portion with the left. 

From the fact that the free end of the roller is first applied, it is 
called its " initial extremity," and the other end of the strip, now in 
its centre, the " terminal extremity," and the roller is said to be single- 
headed. When the strip is rolled from both of its extremities the 

Fig. 81. 




Bandage-roller. 



double-headed roller is formed, and that portion intervening between 
the two heads is called its " body," while both ends are then "terminal" 



PREPARATION AND APPLICATION OF BANDAGES. 135 



and at the centres of the cylinders. This roller is made in the same 
manner as described above. 

The machine (Fig. 81) for rolling bandages is very simple, consist- 
ing of a metallic spindle supported upon two uprights or columns, 
and revolved by a crank ; opposite the spindle there are two horizontal 
bars, or a board with two parallel slits cut in it, for the purpose of 
supporting and regulating the tension upon the strips. To render 
the machine stationary while it is being used, it is fastened to a table 
or bench with a large wooden screw and clamp. 

The manner of applying a single-headed roller is to take it by its 
extremities between the thumb and the second and third fingers, or 
to hold it in the palm of the 

hand between the thumb and Flg * 82, 

the four fingers ; in either case, 
that part of the cylinder to 
which the free portion is tan- 
gent ought to look from the 
surgeon. Then unwind the 
initial extremity a little and 
lay its external surface upon 
that part of the circumference 
of the limb opposite to the 
injury, and hold it there with 
the point of the finger or 
thumb of the left hand, while 
two or three circular turns are 
being made to secure it from 
slipping. Now the turns may 
be successively applied, each 
covering in a half or two- 
thirds of the width of its pre- 
decessor, until the entire roller 
is exhausted. But owing to 
the conical shape of the limbs, 
a bandage applied circularly 
in this manner will press upon 
the surface by its superior 
border only, leaving the lower one standing off from the part, and 
forming pockets or puckers ; to avoid these an oblique direction must 
be given to the turns, forming what are called doloires, each of which 
overlaps two-thirds of the one that precedes it ; if they simply touch 
by their edges, the spiral is said to be rampant. The turns of a 
roller applied in this manner are apt to slip, and cannot be laid down 
smoothly enough upon a very conical part to make uniform pressure 
upon it, and we are, therefore, compelled, in order to avoid this in- 
convenience, to change its direction at every turn ; in other words, 
to make what are termed " reverses." This is done in the following 
manner : When the roller has passed the point upon which a reverse is 
designed to be placed, a distance of five or six inches, the turn is held 
against the limb by the point of the index finger or thumb of the left 
hand, while, with the right, the roller is drawn backwards and folded 




Mode of applying the roller baudage. 



136 SECOND PIECES OF DRESSING, OR BANDAGES. 

upon itself by pronating the hand, as seen in Fig. 82, so that the supe- 
rior border of the turn becomes the inferior, and the external face the 
internal ; the reverse must then be tightened by gentle traction upon 
the roller. 

To give a neat appearance to the bandage, these reverses may be 
arranged in the same vertical line upon the limb; and to insure the 
greatest uniformity of pressure the oblique edges which they form 
by folding must not exceed the width of the roller, else they are liable 
to constrict the limb like cords. 

The direction of the turns, as they are generally applied by a right- 
handed person, is from left to right, that is, from without inwards for 
the right leg. and the reverse for the left leg ; but this is entirely a 
matter of choice, for the best rule is, that that method of applying a 
bandage should always be selected which will insure the neatest and 
most efficient result. 

In employing the double-headed roller, there is a little more diffi- 
culty, perhaps, encountered than in the previous case. Gerdy directs 
it to be accomplished in the following manner : " Seize the two cylin- 
ders in both hands, apply the external surface of the intermediate 
portion or body upon a point of the circumference of the part which the 
bandage is to cover ; afterwards unwind at the same time and to an 
equal degree the two cylinders around the part until you have carried 
them to a point opposite that at which you commenced the bandage ; 
in this place deviate one of the cylinders obliquely upwards or down- 
wards, continue on the contrary to carry the other with its band in a 
horizontal line until the latter meets the unwound portion of the first, 
which it covers and crosses, forming an acute angle ; then turn and 
reverse obliquely the first cylinder and its oblique unwound portion 
upon the circular part of the second cylinder, which covers in and 
crosses it ; afterwards making the two cylinders pursue their original 
direction, bring them a little above the point of departure and com- 
mence again in front the same manoeuvre that has been done behind ; 
proceed in this manner until the roller is exhausted, and fix the last 
convolutions, as well as one of the terminal ends, b}^ horizontal cir- 
cular turns made with the more voluminous cylinder." 

There are several modes of fixing the terminal ends of roller 
bandages ; that most commonly employed is to secure them with pins 
which should be always introduced with their heads looking towards 
the free extremity of the roller ; for if the point projects in that direc- 
tion, the traction of the bandage will soon cause it to stick out and 
catch in everything coming in contact with the part, or it may wound 
the hands of the patient or surgeon. If the end of the strip is narrow, 
its corners may be turned under so as to form an acute angle into 
which one pin may be introduced to confine it ; if it is broader, a pin 
in each corner and one in the centre will be necessary. Sometimes a 
couple of pieces of tape are sewed to the end of the roller, which is 
then fastened by a double bow-knot. Bandages of the fingers are 
often secured by simply winding a thread around them several times 
and tying it. By splitting the free end of the roller to the extent of 
five or six inches, two tails are formed, which may be bound around 



SYSTEM OF BANDAGING. 137 

the finger and knotted. Still another way of securing a bandage is to 
permit a few inches of its initial extremity to remain free, and, when 
the roller is exhausted, tie the terminal and initial ends in a bow-knot. 

SECTION II. 

SPECIAL SYSTEMS OF BANDAGING. 

1. Mayob's System of Bandaging. — Although simple square 
pieces of cloth variously folded were often employed by the ancients 
in bandaging, yet it remained for M. Mathias Mayor, of Lausanne, to 
systematize and base upon uniform and rational principles their 
employment. He has also added others of his own invention, and has 
designated them all by names grounded upon a scientific anatomical 
nomenclature. For instance, he commonly employs two or more ana- 
tomical terms joined together to designate each bandage; the first 
term pointing out the part to which its body or base should be 
applied, and the second that over which its extremities should be 
tied. Thus, the fron to-occipital triangle indicates that the base of the 
triangle is over the forehead, and that its ends are fastened upon the 
occiput ; so in the fronto-cervico-labial cravat, the body of the band- 
age is upon the forehead ; it is crossed upon the neck, and its ends are 
finally fastened in front of the lip ; and in like manner the same plan 
is carried out through the whole series. 

This system is ingenious and really useful under certain circum- 
stances ; but it certainly will never even partially supplant the use 
of the ordinary bandages, much less become generally adopted, as 
was intended by M. Mayor. Although the highest meed of praise 
has been accorded to the system by most surgeons, yet they have 
never failed to recognize several essential defects in it which will 
always restrict its employment within very narrow limits. For 
instance, these bandages cannot be expected to, and they do not, act 
efficiently in varicose veins, oedema, and some cases of hemorrhage, etc., 
where a uniform and continuous pressure is necessary ; in fractures 
they are all but useless as permanent dressings, on account of their 
want of solidity and power to maintain the reduction of a broken 
bone. No one will deny this statement should he attempt the treat- 
ment of a case of oblique fracture of both bones of the leg with 
cravats and the hyponarthecic board. These are objections of a vital 
character ; but there are others of a more trivial nature, among which 
may be mentioned the pressure of the knots by which the bandages 
are fastened, as well as the creases and folds which are necessarily 
formed by them upon parts already sensitive and tender. 

On the other hand, the advantages of the system are, first, should 
the surgeon be so situated that more efficient bandages and apparatus 
cannot be obtained, as often happens during the exigencies of war 
both to army and naval surgeons, he will find in the handkerchief and 
its modifications the best possible substitute for them ; secondly, the 
preparation and application of these bandages are so simple that, with 
very little instruction, any intelligent person can manage them suffi- 
ciently well to put on a provisional dressing, the timely use of which, 
in battle or after accidents, may determine the future fate of a pa- 



138 SECOND PIECES OF DRESSING, OR BANDAGES. 

tient ; thirdly, the materials of the bandages — a common handkerchief 
or square piece of muslin, or any kind of cloth — are to be found 
everywhere, and always ready prepared for immediate use. 

These are the prominent disadvantages and advantages of M. Mayor's 
handkerchief system ; and although he did not design it to supplant 
the place of the ordinary method of bandaging at once, yet he believed 
that rigorously it might do so under all circumstances. „The experi- 
ence of other surgeons is so different, however, from that of M. Mayor, 
that they only employ his bandages to retain other dressings in place, 
to act as simple supports to parts, to serve as provisional dressings, 
and, lastly, to be used under circumstances of necessity where the roller 
and other bandages are unattainable. 

M. Mayor prepares all of his bandages from one primitive form — ■ 
a square piece of muslin (Fig. 83) — which is itself rarely used. 



Fig. 83. 



I 

Is 



I 
Jr~i ^ j 1 

;::iT tt r ~~Z~-l^~~ \T... 



"iff 



lU== 





Fig. 


84. 








isisiii 




; :;. ; - : ■ 


m- 




:; 


P i ts! l .i ( -...ir,.|.n HnjHjjipi 




wmm 


^ 


::.::. 


?mmsi 



The square. 




The triangle. 



1. The Oblong (Fig. 84) is formed from the square by twice folding 
the latter in the direction of the transverse lines. 

2. The Triangle (Fig. 85) results from the folding of the square in 
the direction of the diagonal line. The middle third of this line Mayor 
calls the base of the triangle, and the two lateral thirds the " extremi- 
ties," or chiefs, and the angle opposite the base the "apex," or "summit." 

3. The Cravat (Fig. 86) is prepared from the triangle by bringing 
the apex to its base, and folding it a number of times upon itself, to 
obtain the width and thickness we desire it to have. 

Fig. 86. 



The cravat. 



4. The Cord (Fig. 87) is nothing but the cravat twisted upon itself. 
"We shall consider the special application of these bandages in 
Chapter VIII. 



THE INDICATIONS ANSWEKED BY BANDAGES. 139 

Fig. 87. 



The cord. 



2. M. Eigal's System of Bandaging. — M. Eigal, animated by 
motives similar to those which induced M. Mayor to adopt his system 
of handkerchief bandages, has also proposed one of his own, differing 
from Mayor's in two principal respects. 1st. Observing that the cra- 
vats and triangles of that author formed creases and puckers when 
applied to the body, which caused them to be easily displaced, he 
endeavored to remedy this defect by cutting the pieces of muslin into 
different shapes, so that they might rest smoothly upon the surface. 
2d. Observing also that, their ends being firmly knotted together, the 
bandages were thrown from their proper position by the movements of 
the patient, he, to obviate this, introduced the use of gum-elastic cords 
to fasten them. "Which combination," says M. Eigal, "has the advan- 
tage of fastening the pieces of muslin together in such a manner that 
they cannot be deranged. In spite of the most varied movements of a 
patient, the degree of compression determined by the surgeon remains 
sensibly uniform; the play of the lower jaw, that of the osseous walls 
of the thorax, the different inclinations of the trunk, the alternate 
flexion and extension of the members, all these do not change at all 
the first arrangement established." 

The same objections which have already been made to Mayor's 
system may be urged with still stronger reason against Eigal's; at the 
same time, it wants one of the peculiar advantages of the former, viz., 
that the materials are always at hand. Elastic threads of different 
sizes and lengths can, probably, be found only in cities, and any mili- 
tary or rural surgeon so well off in resources as to possess a supply 
of these will be most likely to have also at command other means 
superior to the bandages of Eigal. Yet the ingenuity displayed in 
their construction, and their fitness in certain cases, demand for them 
a cursory description. We have, therefore, considered their special 
application in Chapter YIII. 

SECTION III. 

THE INDICATIONS ANSWERED BY BANDAGES. 

As we propose to study the bandages in anatomical order, it will be 
necessary to devote a few pages to the consideration of the indications 
which they are capable of fulfilling. 

Notwithstanding the multiplicity of surgical bandages and apparatus, 
they may all be reduced to a few classes expressive of their mode of 
action and the common principles upon which they are founded. Of 
course such a classification cannot be rigidly adhered to, inasmuch 
as the same bandage may at one time belong to one class, and at 
another to an entirely different one ; or, again, its mode of action may 
assimilate it to two, and even three, different classes at the same time: 
thus, a bandage may be at once compressive and expelling, or pro- 



140 SECOND PIECES OF DRESSING, OR BANDAGES. 

tective, compressive, and expelling. Indeed, there are but few band- 
ages whose action is single ; we often lay a piece of cerated muslin or 
other cloth upon an ulcerated leg, and secure it with a few turns of 
the roller, to protect the sore from external irritants while the healing 
process is being perfected, and we also bandage with the roller an 
©edematous leg, with the object of making compression only; but 
when both of these conditions obtain in the same leg, the bandage 
necessarily becomes both protective and compressive. 

Yet, for perspicuity, we shall speak of the actions of these classes as 
if they were entirely distinct, and will refer occasionally to those special 
cases of disease in which their action is markedly seen ; and, to further 
develop the subject, we shall not hesitate to allude to the action of 
certain surgical instruments based upon the same principle. 

One of the simplest indications answered by a bandage is to protect 
parts from the contact of irritating agents, as when we put a shield 
over the eye, to ward off the glare of the light in various diseases of 
that organ attended with an increased sensitiveness of the retina; or 
when we cover delicate and granulating surfaces with a fine compress, 
to defend them from the action of dust, or the clothes of the person, 
or his bed. Here the object is simply to interpose a defence between 
the external agents and the surface of the body; but it happens most 
frequently that, besides performing these functions, the bandage serves 
the further purpose of a vehicle of certain medicaments, as simple 
cerate, the narcotic ointments, basilicon ointment, or other substances, 
which are spread upon its under surface for the purpose of diminishing 
morbid irritability, altering diseased action, stimulating indolent granu- 
lations, or of correcting the fetor of suppurating discharges. 

An equally simple action is that of the retaining bandages, which 
are intended to hold dressings upon parts, or to prevent organs from 
again escaping from their natural cavities after having been once 
replaced. It is upon this principle that the different kinds of trusses, 
pessaries, &c, have been constructed. In fractures, also, the apparatus 
used in their treatment rather retains broken bones in their normal 
position by offering a solid resistance than by any actual force of com- 
pression. It could scarcely happen that any amount of compression 
brought to bear upon a fractured bone, by bandages or apparatus, 
would establish the normal relations of its fragments, if displaced, 
before the reduction has been accomplished ; and in this case no such 
force will be required; the retaining power alone of the apparatus will 
be all that is needed to maintain the reduction. 

In the hernial protrusions of adults, the elastic resistance of the 
truss-spring prevents the bowels from escaping externally, and the 
truss has generally to be worn the balance of the patient's life ; in 
children, however, a well-fitting truss, with a pad bearing upon the 
whole length of the inguinal canal, will not only hinder the extrusion 
of the abdominal viscera, but often effect a radical cure by obliterating 
the neck of the hernial sac by the compressive force of the pad. 

In prolapses of the uterus, vagina, and anus, retentive bandages 
have been employed with success. Those intended for the two former 
organs are called pessaries. Of these there are two forms : the first 



THE INDICATIONS ANSWERED BY BANDAGES. 



141 



consisting of a metallic instrument to be introduced into the vagina 
and supported in situ by an external bandage, as the bilboquet pessary ; 
the second kind have no external support, but take their point (Vappui 
upon the vaginal walls : the latter are now almost exclusively used in 
this country. Pessaries introduced into the vagina not only impede the 
descent of the uterus by the resistance which they offer to that organ 
in consequence of being supported themselves by the walls of the 
vagina, but at the same time they distend the upper part of this canal, 
which contributes largely to their retentive power. 

In prolapse of the rectum, the retentive bandage consists of a perineal 
strap which bears upon its upper surface a pelote or knot-like projection 
intended to press against the anus; this strap is held in place by being 
buckled in front and behind to another strap passing around the loins. 
A better form, however, of this bandage is that where the pelote is sup- 
ported at the extremity of a steel spring which takes its point cVappui 
from a pelvic strap. The principle of retention is involved in a great 
number of other bandages, but the above examples sufficiently illus- 
trate it. 

Suspensory bandages are used to support swollen and pendulous 
organs, to prevent their weight causing dragging pains, and to facili- 
tate the circulation of blood in them. The female breast sometimes 
becomes greatly enlarged, either from simple inflammation or can- 
cerous disease, and demands that it be effectually supported. "We 
accomplish this by using one of the crossed bandages or slings of the 
breast, or by adhesive plaster, as seen in Fig. 88. The strips should 




Mode of supporting the breast by strapping. 



be sufficiently long to pass around the breast and shoulder, and every 
part of its surface except the nipple must be covered in. 

The testicles suffer in a similar manner, and are maintained in an 



142 




elevated position by the well-known woven suspensory bandages of 
the shops. 

Large and irreducible hernial protrusions also require some sort 

of a supporting bandage, to 
Flg ' 89, prevent those painful dragging 

sensations in the abdomen 
which their weight produces. 
These are sometimes so large 
that they contain most of the 
abdominal viscera ; the stomach 
even may become partially ex- 
truded, and in these cases the 
patients are destined for the rest 
of their natural lives to carry 
these enormous tumors in a 
sling. In women the abdomen 
sometimes becomes pendulous, 
and requires to be efficiently 
supported, and for this purpose 
the bandage seen in Fig. 89 is 
well adapted. It resembles the 
corset usually worn by ladies, 
and is rendered firm and elastic 
by vertical strips of whalebone 
introduced between the outer 
and inner surfaces ; to prevent 
it slipping up, which it ought 
not to do, however, if well made, two thigh straps are attached to the 
bandage. 

Professor N. E. Smith, of Baltimore, has generalized the principle 
of suspension in the treatment of fractures, and there is no doubt 
but that his anterior wire splint is an improvement upon the ordi- 
nary suspensory apparatus ; it is of especial value in those cases of 
fracture attended with wounds of the soft parts at the seat of the 
injury. I have used a wire splint to suspend the arm in gunshot 
wounds of the palm of the hand with decided advantage ; it permits 
the arm to be placed in any position, either for the renewal of the 
dressing and cleansing the parts, or to facilitate the escape of pus ; 
the suspending cord may be attached above to the ceiling or to a hoop 
placed over the injured limb. 

Expelling bandages are such as cause any accumulated secretions to 
flow out from the cavities in which they may be contained by exercis- 
ing compression, as is seen in cases of large phlegmonous and diffused 
abscesses where an expelling bandage is applied to force the secreted 
fluids externally and to bring the opposite walls of the cavity in con- 
tact. With the same view the proper bandaging of a suppurating 
stump will have an important influence upon the result of the opera- 
tion, and especially when this has been effected by the flap method ; 
for, under these circumstances, pockets and purulent collections are 
more apt to form than when the circular operation is performed. I 



Velpeau's bandage for supporting a pendulous 
abdomen. 



THE INDICATIONS ANSWERED BY BANDAGES. 



143 



think I have seen death take place in several instances after amputa- 
tion in the hospitals, during the late war, from pyemia, the result of 
allowing the end of the bone to be bathed in acrid pus. In various 
cases of fistulas and sinuses expelling bandages are also used. 

Uniting handages are employed to hold the margins of wounds 
together while nature effects their union. Generally, the surgeon de- 
pends upon adhesive plaster, position, pressure, and the suture, as the 
most efficient means to accomplish this object. Yet these may be 
materially assisted by the uniting bandages, such as those for horizon- 
tal and vertical wounds. In some wounds uniting bandages are in- 
dispensably necessary, as in transverse incisions upon the throat, 
which require the head to be flexed upon the chest. To support the 
suture after the operation for harelip, Mr. Dewar, of Scotland, invented 
a contrivance consisting of a circular elastic steel spring, reaching 
from the back and base of the skull forwards to each side of the 
fissure in the lip, and terminating there in two little pads ; two verti- 
cal straps hold the spring in its place. The pads press the tissues 
forwards, and thus relieve the strain upon the twisted suture holding 
the edges of the fissure together, as seen in Fig. 90. 

The object of dividing bandages is exactly the reverse of the pre- 
ceding class, and they are much 

more difficult of management. In Fig- 90. 

wounds attended with considerable 
loss of substance, as those from 
burns, gangrene, &c, dividing 
bandages are employed often with 
the best results in preventing, or, 
at least, alleviating, the contrac- 
tion of the cicatrices resulting 
from them. Cases of this kind 
sometimes occur which, if aban- 
doned to the curative effects of 
nature alone, would present a 
frightful amount of deformity and 
loss of function of important or- 
gans, as we see in burns of the 
neck, in which the contracting 
cicatrices sometimes draw the 
lower jaw down upon the chest 
in such a manner that the teeth 
are exposed, and cannot be brought 
in apposition, and the saliva 
dribbles away from the mouth 
involuntarily, thus destroying at once two important steps in diges- 
tion — mastication and insalivation — and necessarily impairing in a 
serious manner the nutrition of the patient. In the upper extremity 
cicatrices may bind it to the side of the chest, or destroy the functions 
of the fingers. From this it may be seen that it is of the greatest im- 
portance to attend to the early treatment of such cases with dividing 
bandages ; for although plastic surgery has done much to relieve the 




Dewar's apparatus for supporting the suture 
in hai'elip. 



144 

deformities following such injuries, yet we must depend upon the 
former for satisfactory results during the cicatrizing process, and en- 
deavor to save the patient from a future dangerous and often unsatis- 
factory surgical operation. There are other means, besides these band- 
ages, used by the surgeon to prevent the premature union of wounds. 
For instance, after the operation for fistula in ano, he packs lint in 
the incision to hinder the agglutination of its edges before the bottom 
of the wound has healed. He also introduces into the orifices of cer- 
tain canals, after being injured, and into the punctures made in ab- 
scesses, bits of lint, elastic bougies, &c, to prevent unwished-for closure. 

Of all the indications which bandages fulfil, there is, perhaps, no 
one as important as that of compression, considered either in the 
extent of its applicability or in the magnitude of the cases in which it 
is employed. The use of a large number of bandages and surgical 
instruments is based upon this principle. Moderate pressure upon 
parts of the human body aids their contractile power and excites 
their absorbents to an increased action, so that under its influence 
large tumors and certain organized effusions often disappear. When 
it is increased and continued, the nutritive functions are disturbed 
and atrophy is the consequence. When, again, the pressure is carried 
still further and becomes excessive, the parts below the point where 
the compression is exercised become numb, torpid, and insensible ; 
their circulation is arrested; they grow cold, and finally mortify. In 
cedematous conditions of the extremities, particularly in the legs, 
gentle pressure, exercised by a neatly-applied reverse turn bandage, 
will cause the effusion to disappear, and give tone to the parts by cor- 
recting the abnormal dilatation of the capillaries and smaller blood- 
vessels. Of course it is necessary, for all this good to follow, that the 
effusion should not depend upon organic disease of interior organs 
essential to life. 

Some surgeons are in the habit of applying a roller bandage to 
the entire length of a fractured limb, with a view of preventing 
the spasmodic action of the muscles, while others consider it either 
unnecessary or inefficient, believing that the splints commonly em- 
ployed in such cases will exercise all the compression necessary to 
effect this object. As to the relative efficacy of one or the other of these 
plans of making compression, the question can soon be decided if we 
but reflect that a contracting muscle increases in diameter and dimi- 
nishes in length, so that it is very apparent that any force brought 
counter to this diametric enlargement must diminish the extent of 
muscular contraction, if it does not entirely prevent it ; and the roller 
bandage, pressing uniformly upon the whole extent of the muscular 
surface, as it does, and exactly in an opposite direction to the expansive 
force of the muscles, must be more efficient in controlling this than 
splints, which exercise compressive force upon a very narrow extent 
of surface, and do not, therefore, hinder the muscles spreading in a 
direction at right angles with the planes of the splints — that is, in the 
direction in which they are not opposed. 

There does not appear to be any difference of opinion as to the 
advantages of applying compressive bandages to stumps after amputa- 
tion of the limbs, for the reason that, under such circumstances, one of 



THE INDICATIONS ANSWERED BY BANDAGES. 145 

the points of attachment of the muscles being destroyed there is no 
obstacle to their contracting and thereby drawing up the flaps. After 
watching the progress of numerous amputations I am convinced that, 
with more skilful bandaging and shorter flaps than are commonly seen 
in hospitals, not only can better stumps be obtained, but, what is of more 
importance, the period of healing can be abridged and thereby more lives 
be saved. The chief error I observed during the war, in amputating, 
consisted in cutting the flaps too long, so that after one battle, of a large 
number of these operations but one patient had the flaps too short (and 
the flap operation was generally adopted), while a large number had 
them too long. Of the latter cases there was one in particular, a man 
whose thigh had been amputated, in which the bone had been sawn 
through in the upper third, and the incisions made near the lower 
third, so that the soft parts formed two huge flaps, an anterior and a 
posterior, which, in spite of the most skilful attention, kept suppurating 
until the patient died from sheer exhaustion. There was no doubt in 
this case that, had the operation been performed otherwise, and the 
stump properly bandaged, the patient would have made a happy re- 
covery. I was enabled to follow up and take accurate notes of thirty- 
five cases of amputations ; good stumps were obtained in all, and the 
circular operation, with flaps of the skin and cellular tissue only, was 
adopted in every case, care being always taken to have just enough 
of the soft parts to cover the end of the stump, and no more, and to 
bandage carefully. I saw one case, that of an officer, in which the 
thigh had been amputated at three different points in consequence of 
the retraction of the soft parts from improper bandaging. 

The consideration of compression as a hemostatic means we shall 
defer until we come to the subject of hemorrhage. 

Somewhat connected with this, however, is the subject of aneurism, 
in the treatment of which compression has, within the last twenty-five 
or thirty years, assumed great importance. A number of scores of 
years ago, recourse was often had to direct pressure upon aneurismal 
tumors, but it was not until 1760 that Vernet, a French surgeon, 
introduced the present practice of making compression upon the 
course of the artery above the tumor. After having made this 
important step, the treatment of this disease was far from being 
scientific and based upon exact observation ; for the idea entertained 
was to bring such a compressing force upon the artery as to obliterate 
its cavity by pressing its walls into contact, and in doing this great 
pain and suffering were necessarily inflicted upon the patient, so that 
few had either the nerve to begin, or the endurance to sustain such a 
mode of treatment. The true principle was, however, at last dis- 
covered and firmly established by the labors of several eminent 
Dublin surgeons and others, among whom were Bellingham, Dutton, 
Carte, and Tafnel. They discovered that it was only necessary to 
make such a degree of compression as to retard the current of blood 
through the aneurismal tumor in order to bring about its obliteration, 
and with this view they invented improved instruments. 

Dr. Carte's compressors are seen in the annexed wood-cuts. Fig. 91 
shows an instrument for the cure of femoral and popliteal aneurism, 
10 



146 THE INDICATIONS ANSWERED BY BANDAGES. 

Fig. 91. Fig. 92. 




Carte's compressor for femoral and popliteal aneurism. 



Carte's compressor for aneurisms of the 
upper extremities. 



and Fig. 92 one for aneurism of the upper extremities. Fig. 93 is 
Hoey's clamp. With these instruments, each having but a single 
pad, the compression may be conveniently applied to any part of 

the course of an artery; but as this can- 
Fig- 93 - not be borne long, in conducting the treat- 
ment of a case it will be necessary to use 
two of the instruments at the same time to 
alternate the pressure upon different points. 
This object is, however, better attained with 

Fig. 94. 





Hoey's clamp. 



Gibbons' modification of Charriere's compressor. 



the compressor of Charriere, as modified by Dr. Gibbons, of Phila- 
delphia, which consists, as represented in the figure (Fig. 94), of a long, 
broad, and concave metallic plate or gutter, which is applied to the 
under part of the limb, and has attached to its side three steel semi- 
circles spanning half of the limb, and bearing at their extremities 
little pads, moved by screws. When the apparatus is in use one of 



THE INDICATIONS ANSWERED BY BANDAGES. 147 

these pads must be screwed down upon the artery so as to interrupt 
the flow of blood through it, and kept there as long as the patient can 
bear the compression comfortably. When it causes uneasiness, the 
next pad is to be screwed down and the first one removed ; we con- 
tinue in this manner to alternate them during the treatment. In a 
case of ulnar aneurism I employed the following instrument, which 
possesses a good deal more steadiness than Charriere's : — 

First, two well-tempered steel rings, of suitable diameter, were 
selected, and connected by two metallic bars, keeping the rings from 
each other at the distance of the shoulder from a point just above the 
olecranon. One of these bars had a width of two inches, was concave, 
and fitted to the outside of the limb ; the other was narrower, and 
supported three pads at equal distances of its length, at the ends of 
long screws working through it ; this bar was also movable, to corre- 
spond to the course of the brachial artery, and could be secured at 
either end by thumb-screws. This apparatus, covered with buckskin, 
is ready for use, and, when properly adjusted, pressure is brought to 
bear upon the artery by the pads being alternately screwed against 
it, or, what I think better, by bringing them all down lightly ; for the 
force necessary to interrupt the flow of blood in the artery is thus 
distributed among the three pads, and hence a third part only of it is 
exercised on any one point of the skin at once. 

In many cases of aneurism the patient's health is much shattered, 
and then the compressor may be applied night and morning, allowing 
him the intervening time to take exercise. In my case, the patient 
learned how to manage the instrument, and carried it about with 
him concealed in his coat sleeve. 

The success attending this mode of treatment has been truly gratify- 
ing, and justifies us always in giving it a patient trial before a serious 
operation is undertaken. Compression for a few hours has sufficed in 
some cases to cause the fibrin of the blood to be deposited in the sac 
in such quantities as to convert it into a solid tumor, while in others 
several weeks are generally required to effect this good result. The 
way compression acts in curing aneurism is by retarding the blood in 
the aneurismal sac, where it deposits fibrin, layer after layer, until 
this is either obliterated or its cavity is reduced to a very small 
channel through which the blood flows. 

The treatment of ulcers had long remained in an unsatisfactory 
state until Baynton, an English surgeon, in 1797, introduced his 
plan of curing them by means of compression with adhesive strips. 
According to the statistics of Duchatelet, the average time required 
by the old method in an observation of 690 cases was fifty -two days ; 
while, by compression, that period had been diminished by a half; 
indeed, Velpeau asserts that he has seen a large number of ulcers 
cured by adhesive strips in fifteen or twenty days, that had resisted 
all other methods. As has already been stated, Baynton used a plaster 
containing six drachms of resin to the pound of lead plaster ; and his 
method of applying it was as follows (Fig. 95) : " Several strips of ad- 
hesive plaster, about two inches in breadth, and sufficiently long to pass 
around the limb and leave an end of about four or five inches, were 



148 



THE INDICATIONS ANSWERED BY BANDAGES, 



taken ; also several longitudinal compresses made of soft calico ; and 
a calico roller about three inches in breadth and varying from four to 
six yards in length, according to the size of the limb. One of these 
strips is to be applied to the sound side of the limb, opposite the in- 
ferior part of the ulcer, so that 
Fig. 95. the lower edge may be placed 

about an inch below the lower 
edge of the sore, and the 
ends drawn over the lower 
part of the ulcer, with as 
much gradual extension as 
the patient can conveniently 
bear; the other strips must 
be applied in the same man- 
ner, each above, and in con- 
tact with, the other, until the 
whole surface of the sore and 
the limb is covered from one 
inch below to two or three 
inches above the affected part. 
The whole leg should then 
be covered equally with the 
longitudinal compresses, and 
the roller applied around the 
limb from the toes to the knee with as much firmness as the patient 
can support. One or two circulars of the roller should be first passed 
around the ankle-joint, then as many round the foot, as will cover and 
support every part of it except the toes, and the same continued up 
the limb as far as the knee ; the roller should be carried from the 
ankle upwards in doloires, as many reverses being made as the parts 
require, in order that each turn may be flat upon the limb. Should 
the parts be much inflamed or the suppuration very abundant, the 
applications are to be wetted frequently with cold spring water. The 
patient may take exercise, if he pleases, as this will be found to alle- 
viate the pain and tend to accelerate the cure. The bandage ought to 
be daily applied soon after rising in the morning, when the parts are 
most free from tumefaction ; and the force with which the ends of the 
plasters are drawn over the limb gradually increased as the parts 

Fig. 96. 




Baynton's plan of treating ulcers. 




Bandage scissors. 



return to their natural state of ease and sensibility." When it is 
necessary to remove this bandage, the blunt point of one of the blades 



THE INDICATIONS ANSWERED BY BANDAGES. 149 

of a pair of scissors, such as is represented in Fig. 96, may be passed 
under the strips from below upwards, upon the side opposite to that 
on which the ulcer is, and the bandage cut through its entire length. 
It ought to have been stated that, before the dressings are applied, the 
leg must be scrupulously shaved and cleansed, that no secretion may 
get between the plaster and skin to cause irritation or excoriation. 
The tendo- Achilles may be protected from pressure by a piece of soap 
plaster spread on leather, or. as suggested by Cutler, by a piece of 
thin sheet-lead. Should the strips produce erythema, excoriation, or 
inflammation, they must be discontinued for two or three days, and 
recourse be had to emollients until the above disagreeable accompani- 
ments be removed. The pus coming in contact with the lead-plaster 
sometimes produces a black discoloration of the surface, which is, of 
course, entirely independent of the condition of the ulcer, and may 
be removed easily with a little soap and warm water, when the sore, 
if everj T thing is going on well, will present a healthy red color, and 
granulations becoming firmer and disposed to cicatrize. 

In cases of syphilis, where there is that kind of spreading ulcera- 
tion which creeps under the skin of the groin in every direction, there 
is no better dressing than long strips of adhesive plaster ; their 
centres being placed over the sores, the upper ends carried around the 
pelvis, and the lower ones around the upper part of the thigh between 
it and the scrotum. 

Yelpeau recommends compression with adhesive strips in burns. 
He says : " For a burn of the first degree, an application of strips 
supported by a bandage slightly compressing, and which may be re- 
newed from the fourth to the eighth day, is quite sufficient. If the 
burn is of the second degree, that is, with phlyctenule and without 
phlegmonous tumefaction, I cause the separated cuticle to be removed, 
and cleanse off the exuded matters. The strips are then applied, and 
the cure generally takes place at the end of the second dressing, and 
sometimes of the first, almost always of the third ; if it has not been 
effected by the fourth, this dressing must be abandoned. If there is 
engorgement and tendency to erysipelas, I commence by combating 
these symptoms by means of emollient cataplasms, or bleedings, and 
then apply the strips. If the burn is of the third degree, that is, with 
alteration and destruction of the surface of the cutis, we proceed as in 
the preceding case, and the cure is not the less certain ; only it exacts 
from ten to twenty days. When the burn is yet deeper, when it 
involves the entire thickness of the dermoid tissue, the strips, not 
being able to prevent the necessary destruction of the parts by the 
elimination of the eschar, are of no use until after the removal of this 
latter, until, in fact, after the cleansing of the ulcer. In other respects, 
their application to burns is subject to the same rules as for the treat- 
ment of ulcers." 

This author has also applied the same treatment to phlegmon, in- 
flamed varicose tumors, ganglionic tumors, and scrofulous ulcers of 
the neck after their burrowings and loose edges have been destroved 
by the acid nitrate of mercury, and to chronic pains and other affec- 
tions of the joints. 



150 



THE INDICATIONS ANSWEBED BY BANDAGES. 



In ganglionic tumors, when the patient will not submit to the ope- 
ration of violently rupturing the cyst with the back of a book or 
other appropriate instrument, a spring compressor may be had re- 
course to. 

M. Gariel recommends an ingenious instrument when a uniform 
and gentle compression is required. It consists of a little India-rubber 
bag furnished with a tube and stopcock. In applying it, the bag is 
first emptied entirely of air and bound over the part to be compressed 
by a few turns of a roller. Then, by blowing into the tube, the sack 
is distended and exerts pressure upon the parts beneath it, and the 
degree of compression may be varied at pleasure without disturbing 
the bandage. 

To M. Fricke, of Hamburg, is due the credit of having first called 
attention to the advantages of compression with adhesive strips 
in orchitis and epididymitis. This dressing (Fig. 97) may be applied 
in the following manner : Shave the hair from the scrotum and 
cleanse it thoroughly, then seize the diseased testicle and force it 
to the bottom of the scrotum, and, taking a strip of adhesive plaster 
about half an inch wide and seven or eight inches long, according to 
the amount of swelling, apply its middle to the back part of the 
scrotum and above the gland, and bring its extremities forwards and 
cross them in front, taking care that they lie evenly 
upon the skin, to fix the testicle in this position. 
Successive strips are then applied, each overlapping 
half the width of its predecessor, changing their 
direction as you proceed towards the lower part of 
the scrotum that this may be covered evenly, until 
the whole organ is uniformly compressed ; and 
finally the bandage is finished by passing two or 
three strirps circularly about the tumor to confine 
the ends of the vertical strips. If there is much 
inflammatory engorgement, this dressing should be 
preceded by the application of a few leeches and 
saline purgatives. The adhesive strips should be 
renewed as often as they become loose by the sub- 
sidence of the swelling. 

M. Kecamier advised compression in the treat- 
ment of cancerous tumors. His plan was to use 
disks of agaric, of sufficient size to cover the clis- 
Fricke's plan of treating ease( } p ar t ; interposed between the turns of a roller 
bandage. The disks were of different sizes, and 
piled one upon another, in the shape of a truncated cone with its apex 
downwards, to the height of from two and a half to three inches. 
When the diseased surface presented ulcerated nodules, a little cone 
of agaric was placed upon each of them, and these were then covered 
by a' larger piece of the same material. The outlines of a part will 
readily suggest in what shape the agaric should be formed. Although 
we cannot expect much benefit from the plan in genuine cases of can- 
cerous disease, yet in non-malignant tumors or swellings of any sort 
where a uniform and elastic compression may be advisable, it will 
be a useful one. 




THE INDICATIONS ANSWERED BY BANDAGES. 151 

Dilatation is nothing but compression exercised from within out- 
wards, and has many useful applications in the treatment of narrowed 
canals and orifices. 

The lachrymal canals are sometimes diminished in diameter by 
chronic inflammation, and require dilatation by instruments in order 
that the tears may pass into the nose along their natural channels instead 
of constantly streaming over the cheek, which they will do if these 
passages are occluded from any cause, constituting what is known as 
stillicidium, and which must be distinguished from the same condition 
of things arising from epiphora or an excessive secretion of tears. 

In stricture of the oesophagus, dilatation is also indicated, and is 
effected by bougies of various kinds, gum-elastic, metallic, waxed 
cloth, &c. When the location of the stricture has been made out by 
the explorer (a small curved brass rod mounted with an ivory ball), 
the bougie may be introduced cautiously into the oesophagus, and 
passed through its narrowed part, and permitted to remain a few 
minutes. The operation should be performed at first once every four 
or five days, and as the parts become somewhat tolerant of the pre- 
sence of the bougie, it may be repeated more frequently. The compres- 
sion acts by stimulating the absorbents to take up the plastic matter 
deposited in the mucous and submucous tissues of the oesophagus. 

In contraction of the canal of the neck of the uterus, either when 
it is congenital or proceeds from disease subsequently established 
in that part, dilatation may be accomplished by the persevering use 
of bougies, as will be explained further on. 

Short silver tubes, about four inches long and of different sizes, from 
a quarter of an inch in diameter to an inch and a half, are used to dilate 
a contracted vagina. One of these tubes well oiled may be passed into 
that canal, and retained there three or four hours at a time by a reten- 
tive bandage, such as is employed to retain the female catheter. 

But it is in narrowing of the urethra, or stricture, that the greatest 
number of plans for exercising compression from within outwards 
have been suggested. The dilatation varies in its effects according to 
the manner in which it is employed ; when gradual and gentle, the 
stricture yields almost imperceptibly, while a more violent and sudden 
compression may give rise to inflammation of the urethra, neck of 
the bladder, or the prostate gland. It is accomplished by means 
of certain instruments called bougies, which are made of silver, 
silvered steel, lead, tin, waxed cloth, gum elastic, gutta percha, or wax, 
according to the wishes or necessities of the surgeon. Some import- 
ance has been attached to the shapes of their points, some of which are 
cylindrical, others conical, and some, again, olive shaped or fusiform. 
As to the method of manipulating with these instruments, we shall 
defer its consideration until we come to speak of the catheterism of 
the male urethra. Some special instruments for making dilatation 
have also, at different times, been suggested. Mr. Arnott's dilator con- 
sisted of a membranous tube which he introduced into the urethra 
and distended with water. M. Gariel invented a dilator made of India- 
rubber, in the shape of an ordinary bougie, with its parietes thinned 
at a certain place near its point, and which expanded into a fusiform 



152 



THE INDICATIONS ANSWERED BY BANDAGES, 



sac when air was driven into the tube. A still more ingenious con- 
trivance was brought forward by a French surgeon, consisting of two 
small steel wires continuous at their distal extremities in a rounded 
point, and placed side by side, and curved like an ordinary catheter. 
One of the proximal ends is fixed firmly to a handle and the other to 
a screw moving upon its axis, an arrangement which permits the sur- 
geon to introduce the instrument as a No. 1 bougie (French scale), and 
subsequently to expand it by separating the wires by the action of the 
screw to the size of a No. 30 bougie, without removing it from the 
urethra. Somewhat similar to the preceding is the instrument shown 

in Fig. 98. In using this dilator it 
is introduced closed, and when the 
stricture is passed by simply turning 
the screw the blades are expanded by 
the little pin connecting them together 
at the point marked B. 

Care should be taken to close the 
blades carefully before an attempt is 
made to withdraw the instrument, as 
otherwise the mucous membrane is apt 
to be caught between them and torn, as 
I have seen in two instances. 

A much safer dilator, in inexpe- 
rienced hands, will be found in the 
compound circular catheter of Dr. A. 
Buchanan, of Glasgow. It consists 
of a small round- pointed probe, over 
which silver tubes of different sizes 

Fig. 99. 





Urethral dilators. 



Buchanan's compound circular catheter. 



THE INDICATIONS ANSWERED BY BANDAGES. 



153 



Fig. 101. 



Fig. 102. 



fc&4 



Fig. 103. 



c^no 




"Wakely's dilators for stricture of the urethra. 



Fig. 100. 



are slipped one "upon another, as seen in Fig. 99. In guiding this 
instrument along the membranous and prostatic portions of the 
urethra, Dr. Buchanan advises the finger to be retained in the rectum. 

Mr. Sheppard, of England, employs a dilator (Fig. 100) composed 
of a fine catheter grooved upon one of its sides; in 
the groove a small wire or traveller slides, armed at 
its point with an oval metallic tip ; for the dilata- 
tion of the stricture a number of tips of various 
sizes will be required. 

Mr. Wakely, of London, devised the instruments 
seen in the annexed wood-cuts. Fig. 102 is a very 
small catheter, which is used to pass the stricture; 
into the catheter, the slender steel rod (Fig. 101) is 
introduced and screwed fast, the two together form- 
ing a directing -rod. Over this rod are slipped a 
series of silver conical tubes (Fig. 103), or India- 
rubber tubes (Fig. 104) tipped with metallic buttons 
to facilitate their introduction. The tubes vary in 
size from one just large enough to ensheath the rod 
to the largest, which is equal to a No. 10 bougie. 

Compression plays an important part, also, in 



Sheppard's dilator. 

Fig. 104. 



B 




the action of numerous orthopedic bandages and apparatus, as will 
be seen when we come to study that subject. 



154 THE INDICATIONS ANSWERED BY BANDAGES. 

In most of the instances of the use of compression which we have 
hitherto cited, that agency was exerted over some extent of the sur- 
face, and intended to be conservative ; but there is another sort of 
compression which is only brought to bear upon a very restricted 
space, a line, and hence sometimes called linear compression, and is 
always designed to destroy the life of the parts below the point to 
which it is applied. Under this head fall ligatures and the ecraseur. 

Ligatures. — These act in two modes, according to the way in 
which they are applied ; if the ligature is drawn as tight as possible 
the moment it is put on, and the constriction is complete, the vascular 
supply to the parts beneath it is cut off, and they consequently soon 
lose their vitality, become dark colored, and fall off, leaving an 
ulcerating surface behind ; should the ligature, however, not be drawn 
so tight as this, but only sufficiently to interrupt and diminish their 
vascular supply, the parts below then shrivel up gradually, and as 
the thread makes its way into the tissues, cicatrization follows close 
in its rear, and by the time the constricted portion is separated, the 
surface beneath it is nearly healed. Ligatures are made of various 
substances — annealed iron or silver wire, packthread, catgut, seagrass, 
or silk, and are applied either with the fingers or with special instru- 
ments called porte-ligatures, or knot-tighteners. Care must be taken 
that the ligatures be of sufficient strength to bear the amount of con- 
striction necessary to be made, without breaking or unduly stretching, 
and, in applying them, to cut through the skin previously, that it may 
not be included in the loop, unless, as sometimes happens, the skin 
is diseased, or the tumor of small size, when this preliminary step 
will not be necessary. 

There are several modes of applying a ligature ; when the morbid 
growth is small, such as naevi materni, hemorrhoids, &c., the thread 
may be tied directly around its base or pedicle, and, if necessary 
to prevent its slipping, two hare-lip pins may be previously passed 
through it, at right angles to each other, having entered them 
through the sound skin about an eighth of an inch from the tumor 
and emerging at a corresponding distance upon the other side. Should 
the base of the tumor, however, be larger, a needle armed with a 
double thread may be passed through it; the threads being then 
separated, each of them should be tied around its corresponding 
pedicle. Yery large tumors require to be tied in three or four 
portions. The best needle for this purpose is made of untempered 
steel with an eye near its point, which should be rather blunt, that 
any bloodvessels in the parts through which it passes may not be 
punctured by it. To divide the tumor in three portions, arm this 
needle with a double thread and thrust it through its base in one 
direction; enter it again and pass it back in the opposite direction, and 
finally through a third time as in the first instance, taking care that 
the points of transfixion be at equal distances from each other ; one 
thread only of the first loop is cut, and both of the threads of the 
second loop, which will make five pairs of ends. By thrusting a 
needle with a double thread through the base of a tumor in one direc- 
tion, then a second time in a direction at right angles to the first, and 
finally cutting one of the threads of the loop thus formed, we will 



THE INDICATIONS ANSWERED BY BANDAGES 



155 



divide a tumor in four portions ; and if two of the three pairs of ends 
are first knotted together, by drawing strongly upon the third pair 
and tying them, its whole base will be constricted. 

Mr. Fergusson has improved upon this plan of constricting ngevi. 
He prefers a common surgical needle armed with a double thread ; 
this is thrust through the base 

of the tumor, and one of the Fi s- 105 - 

threads upon that side cor- 
responding with the needle 
is cut in two about three 
inches from the eye; the 
needle is then threaded with 
the end of that portion of the 
divided thread upon the op- 
posite side of the tumor and 
again passed through the lat- 
ter at right angles to its first 
course. When the threads 
are disengaged from the nee- 
dle there will be two pairs of 
ends, which are to be drawn 
tight and tied together in two knots. In this manner, as seen in the 
cut (Fig. 1 05), two t figures of 8 are formed by the threads at right 
angles to each other. 

When the tumor is of such a form that it cannot be divided into 
separate portions by the above plan, the surgeon may have recourse 
to the method recommended by Mr. Erichsen : " A long triangular 
needle is threaded on the middle of a whip-cord, about three yards 
in length; one half of this is stained black with ink, the other half 
is left uncolored. The needle is inserted through a fold of the sound 
skin, about a quarter of an inch from one end of the tumor, and 




Mode of ligating nsevus. 



Fig. 106. 



Fig. 107. 




Erichsen's method of ligating vascular tumors. 



transversely to the axis of the same. It is then carried through, 
until a double tail, at least six inches in length, is left hanging from 



156 THE INDICATIONS ANSWERED BY BANDAGES. 

the point at which it entered ; it is next carried across the base of the 
tumor, entering and passing out beyond its lateral limits, so as to leave, 
as shown in Fig. 106, a series of double loops about nine inches in 
length at each side. Every one of these loops should be made about 
three-quarters of an inch apart, including that space of the tumor, 
and the last loop should be brought out through a fold of healthy 
integument beyond the tumor. In this way we have a series of 
double loops, one white and the other black, on each side, as in Fig. 
106. All the white loops should now be cut on one side and the 
black loops on the other, leaving hanging ends of thread of corres- 
ponding colors. 

" The tumor may now be strangulated by drawing down and knot- 
ting firmly each pair of white threads on one side and each pair of 
black ones on the other. In this way the tumor is divided into seg- 
ments, each of which is strangulated by a noose and a knot ; by black 
nooses and white knots one side, by white nooses and black knots on 
the other, as in Fig. 107." 

Subcutaneous ligature is effected by entering a curved needle armed 
with a thread at any point of the base of a tumor between it and the 
skin. Thrusting it as far as possible, shove its point through the 
skiu, and withdraw the needle ; enter its point a second time at this 
puncture, and pass it along again in its original course until it emerges 
at the first puncture, when the needle is pulled out, and the ends of 
the ligature tied. 

When the loop of the ligature cannot be placed around the tumor 
conveniently, if at all, with the fingers, as happens in polypus of the 
nose and uterus, recourse must be had to porte-ligatures or knot- 
tighteners, the simplest of which is the double canula of Levret; it 

Fig. 108. 



Double canula. 

consists of two metallic tubes immovably connected together, and 
open at both ends, to one of which two little rings are soldered, one 
upon each side. To use the instrument, a piece of silver wire of 
sufficient length is passed into the tubes so as to form a loop, one of 
its ends being twisted around one of the rings, while, with the other 
end, the size of the loop is regulated until the surgeon may have 
satisfactorily arranged it, when that extremity must be drawn tight, 
and also twisted around the second ring. Graefe's knot- tightener 
" consists of a shaft of steel pierced at one extremity by an opening 
through which pass the two ends of the knot already applied ; at the 
other extremity is a vice which, in moving to one side or the other, 
elevates or depresses a movable screw, to which are firmly attached 
the two ends of the ligature. One single turn of the vice suffices to 
loosen or tighten the constriction. This instrument combines great 
simplicity and force." The knot-tightener of Roderic, as modified by 
Mayor, is formed of a chaplet of small balls, representing a flexible 
column, through which the ligature passes by small holes in each ball. 



THE INDICATIONS ANSWERED BY BANDAGES. 



157 



The ecraseur lineaire is an instrument intended to make the slow 
section of the tissues, somewhat in the manner of a ligature. It was 
recently invented by M. Chassaignac. It consists of a strong metallic 
tube through which, for a part of its length, a long screw works, bear- 
ing at its extremity a sort of chain loop, which projects some distance 



Fie. 109. 




Ecraseur. 



beyond the tube ; the screw is moved by a handle, and draws in the 
loop with a slow and steady but irresistible force ; the inner margin 
of the chain is provided with a blunt and saw-like edge which bruises 
and crushes through the tissues. This action of the ecraseur is one in 
which consists all its merits, for it is well known that arteries divided 
by crushing or tearing bleed very little. For the purpose of operating 
upon tumors of the uterus, or in localities where a straight stem could 
not be used with advantage, if at all, the end of the instrument may 
be unscrewed and a long curved beak substituted in its place. The 
division of the tissues must be effected slowly, to avoid hemorrhage; 
the time occupied in an operation will vary, according to the size and 
vascularity of the morbid growth, from five to twenty minutes : the 
handle of the instrument may be made to make one complete revolu- 
tion from every two to twenty seconds. If the tumor has a very 
broad base, it may be ligated previous to the application of the chain 
of the ecraseur. The after-dressings are the same as after operations 
in the ordinary way. The cases in which the e'craseur has been used 
with success are, removal of the penis, testicle, tongue, neck of the 
uterus, and a large number of vascular and other tumors. It has 
even been suggested to remove limbs with it, by first dividing the 
bone with a special instrument, and then cutting through the soft 
tissues with the chain loop. But this is certainly inferior to the ordi- 
nary method of amputation, and all such efforts to render the applica- 
bility of any instrument universal, will in time bring it into discredit 
even in those cases in which it is really useful. 

M. Maisonneuve employs a number of wire threads twisted together 
according to the volume and resistance of the parts to be divided, 



158 CLASSIFICATION OF BANDAGES. 

instead of the articulated chain. The tension of the wires is regu- 
lated by a windlass similar to that of Graefe's knot-tightener already 
described. 

SECTION IV. 

CLASSIFICATION OF BANDAGES. 

The classification of bandages was for a long time involved in the 
greatest confusion, for the reason that their nomenclature was entirely 
unsystematic and without method. Some of them were called after the 
names of their inventors, some according to their form, whilst others 
bore names expressive of their use or their elegance : thus we have 
had the Khomb of Hippocrates, the Tolus of Diocles, the Discrimen, 
the Kiaster, and the Thais. 

Some attempts were made to found a classification upon the mode 
of action of the bandages ; and such terms as uniting, dividing, com- 
pressing, &c., were, therefore, applied to them ; but these divisions, 
as we have already shown, are valueless for the purposes of a nomen- 
clature, as the same bandage may belong to three or four classes at 
the same time. 

Grerdy proposed, in his excellent Treatise upon Bandaging, a classifi- 
cation based upon the geometric figures formed by the different 
bandages ; and it is doubtless the best yet suggested, and has been 
adopted in most of the recent treatises upon bandages. This is the 
classification we intend to follow in this work, so modified, however, 
as to include all the bandages and apparatus coming within the scope 
we have proposed to ourselves. The following table will enable the 
reader to see the whole classification at a glance : — 

SIMPLE BANDAGES. 

Circular Bandages. 

Form circular turns about a part. 
Oblique Bandages. 

Form oblique turns about a part. 
Spiral Bandages. 

Form spiral turns called doloires. 
Figure of 8, or Crossed Bandages. 

Form turns resembling the figure 8 or X. 
Knotted Bandages. 

Form knots at certain parts of their course. 
Recurrent Bandages. 

Form turns running backwards and forwards between two points. 
Handkerchief Bandages. 

Are formed from handkerchiefs, towels, or pieces of muslin. 
Invaginated Bandages. 

Are composed of pieces with slits in them to receive corresponding tails. 

COMPOUND BANDAGES. 
T Bandages. 

Form a figure resembling the letter T. 
Cruciform Bandages. 

Form a figure resembling a cross. 
Sling Bandages. 

Are formed of pieces split at their ends. 
Suspensory Bandages. 

Form a sort of purse. 



BANDAGES FOR THE HEAD. 159 

Sheath Bandages. 

Form a sheath. 
Laced, Buckled, and Elastic Bandages. 

Are formed with buckles, lacings, and elastic cloth. 

MECHANICAL BANDAGES. 

Orthopraxic Bandages : Bandages for Fractures : Bandages for Dislo- 
cations. 
These bandages involve, to a greater or less degree, the application of the 
mechanical powers. 



CHAPTER VIII. 

SPECIAL, OR REGIONAL BANDAGING. 

SECTION I. 

BANDAGES FOR THE HEAD. 

SIMPLE BANDAGES. 

Circular Bandages. 

Of the forehead and eyes. 
Crossed Bandages. 

The monocle. 

The binocle. 

The single crossed bandage for the lower jaw. 

The double crossed bandage for the lower jaw. 

The crossed bandage of the head. 

The crossed bandage of the head and neck. 
Knotted Bandages. 

The knotted bandage of the head. 
Recurrent Bandages. 

The recurrent bandage of the head. 
Handkerchief Bandages. 

The triangular bandage of the head. 

The quadrilateral bandage of the head. 
Invaginated Bandages. 

The invaginated bandage of the lips. 

COMPOUND BANDAGES. 
T Bandages. 

T bandage of the head and ears. 

The double T bandage of the nose. 

The T bandage of the head. 

The double T bandage of the head. 

The T bandage of the mouth. 
Crucial Bandages. 

The crucial bandage of the head. 
Sling Bandages. 

The six-tail bandage of the head. 

The four-tail bandage of the chin. 

The mask. 
Sheath Bandages. 

The sheath bandage of the nose. 

The sheath bandage of the tongue. 



160 

MAYOR'S BANDAGES. 

The circular cravat. 

The occipitofrontal triangle. 

The fronto-occipital triangle. 

The fronto-oculo-occipital triangle. 

The bis-oculo-occipital triangle. 

The occipito-mental triangle. 

The fronto-cervico-labial triangle. 

The facial triangle. 

The occipito-auricular triangle. 

RIGAL'S BANDAGES. 

The cap. 
The half-cap. 
The simple capeline. 
The fixed capeline. 
The Arabic capeline. 
The shepherd's sling. 
The ocular triangle. 

A. Simple Bandages. 

§ 1. Circular Bandages. 

Cieculae "bandages are applied to the different parts of the body by 
means of the roller, the turns of which sometimes overlap each other 
by half or two-thirds of their width, at others the whole width, and 
surround the part at right angles to its axis. They act with energy 
and directness upon the parts beneath, and, therefore, demand watch- 
ful attention, during their employment, that the circulation be not 
arrested, and mortification thereby ensue; for this reason they are 
not well adapted for making compression, but are used generally as 
a retentive means, either to secure the initial extremity of a roller or 
to retain dressings. The circular bandages may be applied to any 
part of the body possessing a nearly uniform diameter. 

The Cieculae Bandage foe the Foeehead and Eyes. Compo- 
sition. — A piece of muslin one yard long and nine inches wide, folded 
lengthwise in four that its lateral edges may be placed within the 
folds ; or a roller two yards long by two inches broad. 

Application. — Place the centre of the oblong compress upon the 
forehead, carry its extremities horizontally around the head, cross 
them over the occiput ; then bring them forwards and fasten them to 
the bandage over the temples with pins. 

If the roller is employed, place its initial extremity upon any point 
of the circumference, secure it with three or four circular turns, and 
pin the terminal end. 

By making a T-shaped incision in the middle of the compress, 
about half an inch from its folded margin, the upper part of the T 
being horizontal and the vertical one corresponding to the anterior 
edge of the nose, the bandage may be made to cover the eyes ; the 
nose passing through the incision will prevent the bandage slipping 
down ; this is called the bandeau. 

Use. — To confine dressings upon the forehead, temples, and eyes, 
as well as to shield the latter organs from the glare of light. To 



BANDAGES FOR THE HEAD, 



161 



absorb any rays of light that may penetrate the folds of the bandage, 
a piece of some dark-colored and light material, as silk or crape, is 
sometimes employed in its composition. When no compression is 

Fig. 110. 




Bandage for the eye. 



needed upon the eyes, but the object is simply to ward off the injurious 
action of light, a green silk shade is commonly employed; with a 
linen flap attached to the bandeau, and hanging over the eye, or 
with the arrangement seen in Fig. 110, cold water may be applied. 



2. Crossed Bandages. 



1st Variety. 



Fig. 111. 




The Crossed- Bandage of One Eye, or Monocle. 

Composition. — A single-headed roller five yards 
long and two inches wide. 

Application. — Place the initial extremity upon 
any point of the circumference of the head and 
secure it by two circular turns, passing from left 
to right, if the object is to cover the right eye, 
and in the reverse direction to cover the left ; 
when the cylinder reaches the occiput at the end 
of the last horizontal turn, depress it sufficiently 
to pass under the ear of the side affected, over its 
corresponding cheek to the inner canthus of the 
diseased eye (it is not, however, to interfere with 
the vision of the sound eye) ; then to the forehead, 
where a reverse is made to alter the direction of 
the roller to a horizontal line ; follow this direc- 
tion by making a circular turn to fasten the reverse upon the forehead, 
continue around to the occiput, depress the roller to pass again beneath 
the ear and over the cheek of the diseased side to the forehead, where 
a second reverse is made, then cover this by a horizontal turn ; pursue 
this course, alternating circular with reverse turns three or four times, 
and terminate the bandage by two horizontal turns around the head. 
Another mode of applying the monocle is, instead of making reverse 
turns upon the forehead, to carry the roller over the parietal pro- 
tuberance, and to alternate the circular and oblique turns thus formed. 
(Fig. 111.) The different turns of this bandage may be secured, with, 
pins, to a muslin cap, which will render it much more secure. 
11 



Monocle. 



162 SPECIAL, OR REGIONAL BANDAGING. 

Use. — To maintain dressings upon the eyes, and to make com- 
pression upon their globes; for the first purpose it is not so well 
adapted as the bandeau, and it is, besides, apt to slip. 

2d Variety of the Monocle. 

Composition. — A roller eight yards long and two inches wide, and 
suitable compresses. 

Application. — If the right eye is to be bandaged, place a compress 
upon it ; permit three or four feet of the initial end of the bandage 
to hang free from the right horizontal ramus of the lower jaw, carry 
the roller over the corresponding cheek and eye, over the left parietal 
eminence to the nape of the neck, then depress it so as to pass under 
the right ear and around the neck to confine the free portion of the 
bandage hanging below the jaw; then to the occiput and over the 
right ear to the forehead, where the free portion which has been 
brought up to this point is reflected over it, and then permitted to 
hang in front of the jaw again; continue around the head to the 
occiput, under the right ear and around the neck, when the free por- 
tion is crossed a second time, reflected over it and carried up to the 
level of the forehead, to be covered by the next circular turn : pursue 
the same course until four turns of the roller cross the eye, and then 
terminate the bandage by circular turns. 

Use. — This form of the monocle is quite solid, and well adapted for 
making pressure upon the globe of the eye. 

The Crossed Bandage of Both Eyes, or Binocle. — 1st Variety; 
with a single-headed roller. 

Composition. — A roller eight yards long and two inches wide. 

Application. — Having laid over the eyes the appropriate compresses, 
place the initial extremity of the bandage upon the forehead and con- 
fine it by two circular turns, arriving at the occiput ; the roller being 
carried from right to left, pass below the left ear, and over its corre- 
sponding cheek and eye to the forehead, where a reverse is to be made 
to give the roller a horizontal direction around the head ; arriving in 
front it meets the turn covering the left eye ; here another reverse is 
made, and the direction of the roller changed, so that it now passes 
over the right eye under the corresponding ear to the occiput : make 
three or four of these oblique turns, and finish the bandage with an 
equal number of circulars to consolidate the whole. 

Use. — To retain dressings upon the eyes ; but it is inferior, for this 
purpose, to the simple bandeau — causing pain by its pressure, and 
being, besides, heavy and heating to the parts below. 

2c? Variety of the Binocle; with a double-headed roller. 

Composition. — A double-headed roller eight yards long by two 
inches wide — one of the cylinders being somewhat larger than the 
other. 

Application. — Place the body of the roller upon the forehead, and 
carry the two cylinders, one upon either side, beneath the ears to the 
nape of the neck, cross them, and at the same time reverse the lower 
turn upon the upper ; then bring them forward under the ears, over 
the cheeks and eyes, to the forehead, where the rollers are crossed 
and carried over the parietal eminences to the occiput, to be again 



BANDAGES FOR THE HEAD. 163 

crossed and reversed as before. The same course is to be gone over 
three or four times, or until the smaller roller is exhausted, and both 
eyes are neatly covered in. Complete the bandage by circulars with 
the remaining unexpended portion of the second roller, and pin its 
extremity. This will be found not so easily disturbed as the previous 
bandage, executed with a single-headed roller. 
Use. — The same as the former bandage. 

The Single Crossed Bandage of the Lower Jaw. Composi- 
tion. — A roller six }^ards long by two inches wide. 

Application. — After having adjusted the appropriate compresses, 
place the initial extremity of the bandage upon the forehead, and 
cover it by two horizontal turns passing from left to right if the 
disease or injury is upon the left side, and vice versa; arriving at the 
nape of the neck, the roller is made to take a course under the ear of 
the sound side, under the chin and over the vertex, passing between 
the external angle of the eye and ear back to the chin ; three vertical 
turns are made in this manner around the head and chin, and when 
the roller at the end of the third turn arrives at the side of the jaw, 
carry it beneath the chin and make a circular turn around the neck 
to the occiput, and ascend obliquely across the side of the head to the 
forehead to make a circular turn around this. This will bring the 
roller again to the nape of the neck, from which it comes beneath the 
ear and around the chin to the occiput, the upper margin of the turn 
being just below the mouth; repeat again this turn, which should 
overlap three-fourths of its predecessor, and continue the roller around 
the side of the neck under the chin up over the cheek across the vertex 
to the chin again, when another turn is made in a similar manner, 
and from its termination under the chin conduct the cylinder around 
the neck to make a circular turn of this part, whence it should pass 
obliquely across the occiput to the forehead to finish the bandage by 
two circular turns around the head. 

In fracture of the neck of the inferior maxillary bone, it is disad- 
vantageous to have the chin pressed upon by the circular turns, as it 
causes the lower fragment to be thrown forwards and upwards. So 
that, in such cases, all those turns of the bandage after the third verti- 
cal turn around the head and chin should be omitted ; and, instead, 
the roller is reversed over one of the temples and the bandage finished 
by two circular turns around the forehead. 

Use. — This modification of the bandage is employed in the treat- 
ment of fractures of the lower jaw, but in some cases, when the object 
is to exert compression upon the side of the neck, the former is pre- 
ferable. 

The Double Crossed Bandage of the Lower Jaw. — Is* Variety. 

Composition. — A single-headed roller seven yards long by two 
inches wide. 

Application. — Confine the initial extremity of the bandage upon the 
forehead by two circular turns, passing from the nape of the neck 
under the right ear around the neck to the front of the left ear, con- 
duct the roller across the top of the head to the occiput, under this to 
the crown of the head again where it crosses the previous turn and 



164 SPECIAL, OE KEGIONAL BANDAGING. 

passes down in front of the right ear and under the chin, in front of 
the left ear across the top of the head to the nape ; make two more 
such turns, and at the end of the third one the roller is to be conducted 
under the chin, around the neck, under the left ear, to the occiput, 
from thence round the forehead to the nape, and around the neck to 
the occiput again. From this point make two circular turns around 
the front of the chin, and then pass around the neck, and return again 
to the place of starting, when the roller is carried across the top of the 
head down in front of the left ear, under the chin over the right side 
of the face and to the top of the head again, where it crosses the pre- 
vious turn and goes on to the occiput. Go again from this point over 
the head, down the left side of the face, under the chin and over the 
right cheek, across the crown to the nape of the neck, and complete 
the bandage by two circular turns around the forehead. 

Use. — This was formerly often employed in the treatment of frac- 
ture of the neck of the inferior maxillary bone ; but the same objection 
can be urged against this as against the former, that is, throwing the 
lower fragments forward. 

It answers well to make pressure upon the parotid region after 
suitable compresses have been placed over it. 

2d Variety ; with a double-headed roller. 

Composition. — A double-headed roller eight yards long by two 
inches broad, with unequal cylinders. 

Application. — Place the body of the bandage upon the forehead, 
carry the cylinders back under the ears and cross them over the nape 
of the neck, reversing the lower one upon the upper ; then bring them 
forwards and cross them under the chin so that they may pass over 
the vertical ramus of the inferior maxillary bone to the top of the 
head where the turns cross, the inferior one being reversed upon the 
superior ; from this point continue to the nape, where another cross 
and a reverse are to be made, and the cylinders conducted to the chin, 
crossed and continued over the angles of the lower jaw to the top of 
the head, crossed and reversed here and then carried back to the nape. 
This course is to be gone over three times in this manner, and the 
turns secured by a circular around the forehead, by that cylinder with 
which the reverse has been made over the back of the neck ; at the 
latter point they will again start, go round the chin, and are crossed 
(the lowest turn being reversed upon the upper to prevent any wrink- 
ling) and brought to the neck in order to make another turn similar 
to the preceding. This brings the two cylinders again to the occiput 
to cross and pass around the neck to the chin, where they are again 
crossed and conducted up over the cheeks to the top of the head, then 
crossed and brought to the nape, crossed there and passed round the 
neck to be crossed under the chin and run over the cheeks to the 
vertex, and crossed again to go to the nape. Here one of the cylinders 
being exhausted, the bandage is terminated by two circular turns 
around the forehead with the remaining roller. 

Use. — This is a much firmer bandage than the one made with the 
single-headed roller ; it is employed in the same cases. 



BANDAGES FOR THE HEAD. 165 

The Crossed Bandage of the Head. Composition. — A single- 
headed roller six yards long by two inches wide. 

Application. — If the right temple is to be covered in, place above the 
right eye the initial extremity of the bandage and confine it by two 
circular turns ; arriving behind the right ear, reverse the roller and 
carry it perpendicularly beneath the chin over the left side of the face 
and top of the head to the place of beginning : in this manner make 
four or five vertical turns, or as many as may be necessary to cover 
in the temple. In the last turn, when the roller comes to the right 
ear, reverse and carry it horizontally around the head twice or three 
times, when the bandage is complete. 

Use. — This is a very simple bandage for retaining dressings upon 
the temple, ear, and angle of the jaw. 

The Crossed Bandage of the Head and Reck. Composition. — 
A single-headed roller six yards long by two inches wide. 

Application. — Place the initial extremity of the bandage upon the 
occiput, and make two circular turns around the forehead, and when 
the roller comes to a level with the ear, carry it obliquely over the 
nape and under the angle of the lower jaw ; make a complete circuit 
of the neck, returning under the angle of. the jaw of the opposite 
side so as to cross the previous turn over the occiput, and continue 
around the forehead ; repeat this twice or three times, and terminate 
the bandage by circular turns around the head. 

Use. — To retain dressings upon the back of the neck, as after the 
use of a seton or blister. 

§ 3. Knotted Bandages. 

The Knotted Bandage of the Head. Composition. — A double- 
headed roller seven yards long by two inches wide, wound in two 
unequal heads; a pyramidally graduated compress, and a small bit of 
adhesive plaster. 

Application. — Close the wound in the temple with the adhesive 
plaster and place over this the compress with its apex upon the 
wound. An assistant holds the compress steady, while the surgeon 
with a cylinder in each hand places the body of the roller over it and 
makes a horizontal turn to the opposite temple, when the cylinders 
pass each other, the lower being reversed upon the upper one, and 
are brought back again to the wound, over which a packer's knot is 
made by twisting them upon themselves so that one of the cylinders 
passes over the vertex and the other under the chin to the sound 
temple, at which point they are reversed upon each other as before. 
When brought to the wound another knot is made with the rollers, 
and then they are conducted circularly around the head. In this 
manner form five, six, or more knots side by side over the wound, 
when the small cylinder will be exhausted, and the bandage will be 
completed by two circular turns with the larger one. 

Use. — To make compression in wounds of the temporal artery 
accompanied with hemorrhage. This bandage should be carefully 
watched, as it often exercises injurious pressure upon the margins of 
the lower jaw. 



166 



SPECIAL, OR REGIONAL BANDAGING. 



§ 4. Recurrent Bandages. 

The Eecurrent Bandage of the Head. (Fig. 112.) — 1st Variety; 
with single-headed roller. 

Composition. — A single-headed roller five yards long by two inches 
wide. 

Application. — Confine the initial extremity at the forehead, or upon 
either temple, by two circular turns, just above the eyebrows, and when 

the roller comes to the nape reverse 



Fig. 112. 




Eecurrent bandage of the head. 



mild 



the bandage and hold the reverse 
with the left fore-finger, while the 
roller is carried along the median 
line to the forehead, where another 
reverse is to be made and the roller 
carried backwards, making a turn 
alongside of the former, and over- 
lapping a third of its width. Ke- 
verse again at nape, and make 
another turn on the opposite side 
of the middle one and overlapping 
it ; continue thus in making these 
recurrent turns, first on one side and 
then on the other, until the upper 
part of the head is entirely cov- 
ered in, when the bandage is to be 
finished by two or three circulars 
around the forehead. 

Use. — To confine dressings upon 
degree of pressure upon it where 



the scalp, and to exercise 
such is necessary. 

This bandage is easily deranged, and not so solid as when made with 
the double-headed roller. 

2d Variety; with a double-headed roller. 

Composition. — A double-headed roller seven yards long by two 
inches wide, and wound into two unequal heads. 

Application. — Place the body of the bandage upon the forehead, 
conduct the two cylinders backwards, above the ears, to the nape of 
the neck, where they are crossed, and the lower roller reversed over 
the upper one, and brought forward, in the median line of the head, to 
the forehead, where the second roller, brought horizontally around, 
crosses and confines it to the part. The roller that has made the ver- 
tical turn is carried again to the occiput to make another turn along- 
side of the first, and covering a third of its width. At this point 
also the horizontal roller fastens it to the occiput, and permits it to 
pass forwards again to form a turn upon the other side of the median 
one. The head is to be covered in this manner by recurrent turns, 
first on one side and then on the other, when, the smaller cylinder being 
exhausted, the large one completes the bandage by two or three circu- 
""ar turns. To render it more secure, the terminal end may be carried, 
vertically, over the head, from ear to ear, and pinned to the reverses. 
Use. — The same as in the preceding case. 



BANDAGES FOR THE HEAD. 167 

§ 5. Handkerchief Bandages. 

The Triangular Bandage of the Head. Composition. — A 
square piece of muslin or a handkerchief of an appropriate size folded 
into a triangle. 

Application. — Place the base of the triangle under the occipital pro- 
tuberance and let its apex hang over the face, then bring the two 
extremities to the forehead and cross them over the apex, when they 
are to be conducted to the nape and tied together, or pinned ; the apex 
of the triangle is now to be reflected over the top of the head and 
pinned. 

Use. — This is a very simple and easily- applied bandage for confining 
dressings upon the scalp. 

The Quadrilateral Bandage of the Head. Composition.— A 
piece of muslin one yard long and two feet wide, and folded length- 
wise in such a manner that one side shall be three inches broader than 
the other. 

Application. — Place the middle of the bandage upon the top of the 
head, with the narrow side upwards, and the folded border posterior, so 
that the lower margin of the broader side will hang about the level of 
the point of the nose, and the lower margin of the other at the level of 
the eyebrows. The anterior angles of the narrow side are now to be 
drawn down and tied beneath the chin, and the other two anterior 
angles folded backwards over the former and tied, or pinned under the 
occiput. The two posterior angles of the folded border are then to be 
drawn down neatly and folded in between the cheeks, and that part of 
the bandage covering them. 

Use. — This is an excellent bandage for retaining dressings upon the 
head, or for protecting the scalp, but it is heavy and heating. 

§ 6. Invaginated Bandages. 

The Invaginated Bandage for Yertical "Wounds of the 
Lips (Fig. 113). Composition. — 1st. A double-headed roller three yards 
long and three-quarters of an inch wide. p. ,, 3 

2d. Two prismatic compresses, each an 
inch and a half long by an inch wide, 
and of a thickness proportionate to the 
prominence of the cheek. 3d. An oblong- 
compress a yard and a quarter long by 
an inch and a half wide. 

Application. — Let an assistant hold 
the compresses half an inch from the 
corners of the mouth, while the surgeon 
lays the centre of the oblong compress 
upon the top of the head and brings its 
two extremities under the chin. Xow 
place the body of the roller upon the 
forehead, carry the two cylinders above The invaginated bandage for vertical 
the ears, cross them on the nape, and ™ unds of the Iips - 

bring them forwards under the ears over the graduated compresses to 




168 SPECIAL, OR REGIONAL BANDAGING. 

the upper lip ; then slip one of them through a slit made in the band 
a few inches below the other one, when both rollers are again crossed 
over the nape, brought forward over the lip, and returned to the nape, 
at which point they are left a moment until the ends of the oblong 
compress have been reflected up and crossed upon the vertex and its 
extremities pinned over the temples, when the cylinders are again 
taken hold of and the bandage completed by circular turns around 
the forehead until they are exhausted. ' 

Use. — To approximate the edges of vertical wounds of the lips, so 
as to prevent traction upon the twisted suture. 

B. Compound Bandage. 
§ 1. T Bandages. 

The T bandages are those which resemble in some manner the letter 
of that name, and are single, when one vertical strip is attached to a 
horizontal one; or double, when two vertical strips are so arranged. 

The T Bandage of the Head and Ears. Composition. — A roller 
three yards long and an inch and a half wide ; about fourteen inches 
from its initial extremity the end of another roller is sewed of the 
same length and width, with an oval opening cut into it correspond- 
ing with the ear. 

Application. — Place the initial extremity of the horizontal roller 
upon that part of the circumference of the head so that the vertical 
one will come in the line of the ear to be dressed, and confine it by a 
circular turn ; then with the vertical band make two or three vertical 
turns around the vertex and chin until it is exhausted ; terminate the 
bandage by fixing the whole by two or three circulars. 

Use. — To retain dressings upon the auricular, temporal, and mastoid 
regions. 

The Double T Bandage of the Nose (Fig. 114). Composition. — 

A strip of muslin one yard long and half an 

Fig. 114. i ncn wide ; upon the middle of this one sew 

ftwo other pieces of the same width and half a 
yard long, at an acute angle. 
Application. — That portion intervening be- 
tween the two vertical strips is placed upon 
the upper lip beneath the nose, while the roller 
of the horizontal band is carried around the 
head, beneath the ears, and tied over the nape 
of the neck. The other two strips are to be 
carried over the top of the head, crossing each 
other at the root of the nose; having reached 
the occiput they are passed under, and re- 
flected over, the horizontal strip, and pinned. 
Double t bandage of the nose. Use. — To retain dressings upon the nose. 

The T Bandage of the Head. Composi- 
tion. — A strip of muslin two yards long and two-inches wide, to which, 
at about a third of its length, is attached, at right angles, another strip 



BANDAGES FOR THE HEAD. 169 

one yard long and of the same width as the previous one. The hori- 
zontal band is to be rolled up in two unequal cylinders. 

Application. — Place the point of junction of the two bands over 
the forehead with the vertical one lying along the median line of the 
head to the occiput, at which point the other bandelette crosses it, 
allowing it again to be reflected to the forehead, where it is secured 
by two or three circular turns. 

A double T may be easily applied in the same manner by using 
two vertical strips instead of one. 

Use. — A very light bandage for confining dressings to the scalp. 

The T Bandage of the Mouth. • Composition. — A strip of muslin, 
four and a half yards long and an inch and a half wide, having sewed 
to one of its margins, about a foot and a half from its end, a second 
piece a foot and a half long and of the same width ; at the point of 
junction, the vertical bandelette is to be split up an inch and a half or 
two inches, and a triangular piece removed from it* immediately below 
this an oval opening is to be made corresponding with the mouth. 

Application. — The nose is thrust through the triangular opening 
and the oval aperture is placed over the mouth, so that the vertical 
band presses along the sagittal suture to the occiput, where the hori- 
zontal band coming from the mouth under the ears crosses it ; it is 
now reflected upwards along the centre of the head, and pinned to 
the previous turn. The two ends of the horizontal portion are taken 
hold of and crossed, the inferior being reversed upon the upper one, 
and brought to the forehead where the bandage is completed by two 
circular turns. 

Use. — This bandage will be found very convenient for retaining 
dressings upon the mouth and cheeks. 

§ 2. Crucial Bandages. 

The Crucial Bandage of the Head. Composition. — A bandelette 
one yard long and from one and a half to two and a half inches wide 
has sewed to it, about six inches from one of its ends, another banda- 
lette two yards long and one and a half inch wide at right angles with 
it, forming a sort of cross, having a long and short arm, the latter 
being about a foot in length. 

Application. — Place the juncture of the bands over the temple, upon 
which the dressings have been laid, with the long one horizontal; 
now conduct the vertical band around the head and chin, and pin them 
over the apex, and then complete the bandage by circular turns around 
the forehead with the horizontal band. 

Use. — The crucial bandage of the head is well adapted by its 
perfect simplicity and lightness to keep dressings in place upon the 
temples, the parotid regions, and the ears. 

§ 3. Sling Bandages. 

The sling bandages are very simple, and often very useful and 
efficient; they consist of a piece of muslin with both of its extremities 
slit into a number of tails; the name is obtained from the resemblance 
they bear to the sling used by the ancients for casting stones. 



170 



SPECIAL, OR REGIONAL BANDAGING. 



Fig. 115. 




The Six-Tailed Bandage of the Head (Fig. 115) — Bandage 
of Galen. Composition. — A piece of muslin a yard and a half long 

and twelve inches wide split at 
each end into three tails, the mid- 
dle one being somewhat broader 
than the other two, leaving a 
central portion or body about 
five inches long. 

Application. — The body of the 
bandage is placed upon the top 
of the head, and the middle tails, 
with their edges folded under to 
resemble a triangle, are tied be- 
neath the chin. The two poste- 
rior tails are now reversed upon 
these and also tied beneath the 
chin, while the two anterior tails 
are conducted backwards, crossed 
under the occipital protuberance, 
and firmly knotted together on 
the forehead. 

Use. — This bandage is very 
simple and well suited for retain- 
ing dressings upon any portion of the upper part of the head. 

The Four-Tailed Bandage of the Head (Fig. 116). Composi- 
tion. — A piece of muslin a yard and a quar- 
ter long and six inches wide, split at each 
end into two tails to within three inches of 
its centre. 

Application. — The body of this bandage 
may, according to the indications, be placed 
upon the forehead, vertex, or occiput. In the 
first instance, the anterior tails are tied be- 
hind the head, and the posterior under the 
chin ; in the second, the anterior tails are 
knotted together over the nape of the neck, 
and the posterior ones in front under the 
chin ; and in the third and last, the anterior 
tails are secured round the forehead and the 
posterior around the neck. 

Use. — As seen above, this bandage will 
answer to hold any sort of dressings upon any portion of the upper 
part of the head. 

The Four-Tailed Bandage of the Chin (Fig. 117). Composition. 
— 1st. A piece of muslin one yard and a half long and three inches 
wide, split at each extremity in two tails to within one inch and 
a half of its centre. 2d. Compresses of suitable size. 

Application. — Any compresses deemed desirable are placed upon 
the lower jaw and held by an assistant, while the surgeon places the 
body of the bandage under the chin, and conducts its anterior tails 



The six-tailed bandage of the head. 



Fig. 116. 




The four-tailed bandage of the head. 



BANDAGES FOR THE HEAD, 



171 



Fig. 117. 




The four-tailed bandage 
of the chin. 



alongside of the face, beneath the ears to the nape of the neck, crosses 
them here and ties them over the forehead. The posterior tails are 
carried vertically in front of the ears to the top of 
the head to be crossed there and brought beneath 
the chin and tied together. 

Use. — The four-tailed bandage of the chin is 
used almost exclusively in the treatment of frac- 
ture of the lower jaw, and it answers a very good 
purpose as a temporary dressing in retaining the 
fragments in position. This is much less trouble- 
some than the cross bandage of the chin, and is 
probably quite as efficient. 

The Mask. Composition. — An oval piece of 
muslin large enough to cover the whole face, with 
suitable holes cut in it to expose the eyes, nose, 
and mouth, and having attached to its superior 
border two pieces of tape a yard long, and two 
similar pieces to its lower border. 

Application. — Lay the mask over the face and carry the upper tapes 
to the nape of the neck, cross' them there, then bring them to the chin 
and tie them together. The inferior tapes are to be crossed in like 
manner over the occiput and fastened around the forehead. 

Use. — To retain dressings upon the face in burns or other injuries. 

§ 4. Sheath Bandages. 

The Sheath Bandage of the Nose (Epervier). Composition. — 
A triangular piece of muslin of sufficient size to cover the nose, with 
two small triangular pieces removed from its lateral angles, and the 
edges afterwards sewed together ; this forms a sort of pocket, which 
will exactly lodge the nose. Now cut 
from its lower part two small pieces 
corresponding in size to the nostrils; and 
to the apex and to each of the lateral 
angles of the sheath sew a piece of tape 
half a yard long. 

Application. — Place the sheath upon 
the nose, and conduct the two lateral 
tapes to the occiput, cross them, and 
finally tie them over the forehead ; next 
carry the tape fixed to its apex in the 
course of the sagittal suture, loop it 
around the other tapes behind, and then 
reflect it forwards, and pin it to the pre- 
vious turn. 

Use. — To retain topical applications 
to the nose. 

The Sheath Bandage of the 
Tongue (Fig. 118). Composition. — A 
small pocket of muslin (a) of a similar 
shape to that of the tongue should be 



Fig. 118. 




172 SPECIAL, OR REGIONAL BANDAGING. 

prepared and fastened by its base to a piece of wire shaped like a 
horse-shoe, and bent twice upon itself, so that it will clasp the chin. 
Fasten a piece of tape a yard long to each wire as it passes in front of 
the chin. 

Application. — The sheath is slipped over the tongue, and the wire 
fitted to the chin ; then conduct the two tapes backwards beneath the 
ears to the nape of the neck, where they are crossed, and afterwards 
tie them together over the forehead. 

Use. — This bandage was invented by Pibrac, a French surgeon, to 
restrain the movements of the tongue in wounds of that organ. 

C. Mayor's Bandages for the Head. 

"We have already described the four elementary forms of all the 
bandages used by Mayor. 

The Circular Cravat of the Head. — As the name indicates, this 
bandage consists of a simple cravat passing circularly around the head. 

Use. — It is intended to replace the bandeau and circular bandage 
of the head. 

The Occipito-Frontal, Fronto- Occipital, and the Bi-Parietal 
Triangles. — The fronto-occipital triangle consists of a triangular 
piece of muslin, a yard and a quarter at its base and seventeen inches 
from the base to the apex. 

Application. — Place the base of the triangle upon the forehead above 
the eyebrows ; draw the apex over the top of the head to the back of 
the neck, and carry the lateral extremities around the head, cross them 
over the occiput, then bring them forward and pin them over the tem- 
ples. The apex is passed under the bandage behind, and turned back 
over the head and pinned. 

The occipitofrontal and the bi-parietal triangles are used in the 
same manner, with this modification, that the base of the triangle is 
placed over the occiput in the first instance, and over one or the other 
temple in the second. 

Use. — To retain dressings upon the head. These triangles are 
much simpler than the other retaining bandages of the head, as the 
recurrent, six-tailed, and square handkerchief, and they supply their 
places very often without inconvenience. 

The Fronto-Oculo-Occipital Triangle. Composition. — A trian- 
gular piece of muslin, seventeen inches from base to apex. 

Application. — Place the centre of the triangle upon the diseased eye 
obliquely, then carry the lateral extremities around the head, one 
below the ear of the diseased side and the other above the ear upon 
the opposite side, cross them behind, and finally tie them together 
over the forehead. The apex of the triangle is conducted diagonally 
across the top of the head, passed under the bandage upon the side, 
and then reflected back and pinned. 

Use. — To replace the monocle. 

The bis-oculo- occipital triangle maybe made by disposing another 
triangle in the same manner upon the other side, and is used as a sub- 
stitute for the binocle. 



BANDAGES FOR THE HEAD. 173 

The Occipital Mental Triangle. Composition. — A triangular 
piece of muslin a yard and a quarter long and .seventeen inches from 
base to apex. 

Application. — Place the middle of the base of the triangle upon the 
top of the head, cross the lateral extremities under the chin, and pin 
them over the sides of the face. The apex is brought forward and 
pinned over either of the temples. 

Use. — Employed in fractures of the jaw instead of the crossed band- 
ages. 

The Fronto-Cervico-Labial Triangle. Composition. — A trian- 
gular piece of muslin a yard and a quarter long and seventeen inches 
from its base to its summit. 

Application. — Place the base of the triangle upon the forehead and 
conduct its lateral extremities around the head to the nape, cross them 
at this point and bring them forward over the lip where they may be 
either crossed or invaginated to regain the occiput; then fasten the 
extremities together. The apex of the triangle is passed beneath the 
bandage behind, reflected upwards, and pinned. 

Use. — After the operation for hare-lip, to remove the strain upon the 
suture; it is intended to replace the other more complicated invagi- 
nated bandages for this purpose. 

The Facial Triangle. Composition. — A piece of muslin a yard 
and a quarter long and seventeen inches from its base to its apex, 
with apertures for the nose, eyes, and mouth made into it. 

Application. — Place the base above the eyebrows, conduct its lateral 
extremities to the occiput, cross them, and then bring them forwards 
again to be tied over the forehead. Draw the apex of the triangle 
down over the face, and carry it under the chin, and finally fasten it 
to that part of the bandage over the neck. 

Use. — To replace the mask ; it is employed in the same cases. 

The Occipito Auricular Triangle. Composition. — A triangular 
piece of muslin a yard and a quarter long and seventeen inches broad. 

Application. — Place the base of the triangle upon the vertex with 
its apex backwards, conduct its two lateral tails downwards over one 
or both ears as desired, and cross them under the chin, when they are 
to be pinned to the bandage over the side of the face. The apex 
may be fastened over either temple. 

Use. — To hold dressings upon the auricular, parotid and maxillary 
regions, and as a substitute for the knotted and T bandages of the 
head. 

D. Eigal's Bandages for the Head. 

The Cap is simply a triangular piece of muslin, with its base 
upon the top of the head, and its lateral tails fastened beneath the 
chin; the open part behind is closed with elastic threads passed 
through eyelet holes or loops. Or, again, a common skullcap split 
open behind and laced in this manner will answer the same purpose. 

Use. — Eetention of topical applications to the scalp. 

The Half-Cap is a vertical section of a skullcap with the elastic 



174 SPECIAL, OR REGIONAL BANDAGING. 

threads attached to its margin. It may be placed upon the forehead, 
occfput, or temples. 

Use. — Same as the former. Both of these bandages may be advan- 
tageously replaced by the simpler ones of Mayor used for the same 
purposes. 

The Simple Capeline consists of a square piece of muslin of 
sufficient size to cover the head when doubled. 

This is folded once from side to side, and its middle portion placed 
upon the top of the head ; the four angles at each side are brought 
together and fastened beneath the chin. The folds between the angles 
are then pinned in front or behind. 

Use. — Eetention of dressings to the scalp. 

The Fixed Capeline. Composition. — A square piece of muslin 
folded in a triangle. 

Application. — Place the base of the triangle in the centre of the 
forehead, and conduct its two lateral tails beneath the chin, cross 
them there, and fasten them over the temples. The two salient folds 
formed between the lateral angles and the apex are laid down and 
pinned; lastly, the extremity reaching down the back is reflected 
upwards and pinned. 

Use. — It serves the same purpose as the previous bandage. 

The Arabic Capeline. Composition. — A square piece of muslin 
folded from side to side. 

Application. — Place the body of the bandage over the forehead, with 
the folded side forwards, then gather up the two anterior angles and 
hold them until they are secured by tying the internal angles of the 
posterior border around the forehead, when they may be drawn under 
the chin and secured with pins. 

The Sling of the Shepherd. Composition. — 1st, a skullcap of 
muslin ; 2d, a piece of muslin six inches long by four inches broad with 
two of its angles perforated with eyelet holes ; 3d, an elastic thread. 

Application. — Place the cap upon the head, and then surround the 
chin by the bandelette with the eyelet holes over the angles of the 
lower jaw. Eest the middle of the elastic thread upon the back of 
the neck, bring its ends forward through the eyelet holes, and pass 
them up over the top of the head, where they are to be tied ; secure 
the threads at the side by two pins. 

Use. — The same as the sling of the chin. 

The Ocular Triangle. Composition. — 1st, a square piece of 
muslin folded once from side to side, and each of the four angles 
perforated with a hole ; 2d, three elastic threads ; 3d, a skullcap. 

Application. — Place one half of the compress obliquely over one 
eye (the right), pin it to the edge of the cap, then reverse the upper 
half upon this, so as to cover in the other eye, and leave a triangular 
space between the two flaps for the nose; then pin the remaining 
angle of the folded edge to the cap. Through the posterior holes pass 
an elastic thread, running behind the neck; connect the anterior holes 
by a similar cord, passing under the chin ; then join the two elastic 
cords together by a third. 

Use. — The same as Mayor's bandage for the eye. 



BANDAGES OF THE NECK AND TRUNK. 175 

SECTION II. 

BANDAGES OF THE NECK AND TRUNK. 

SIMPLE BANDAGES. 

Circular Bandages. 

Circular of the neck. 

Circular of the chest and abdomen. 
Oblique Bandages. 

Oblique bandages of neck and axilla. 
Spiral Bandages. 

Spiral bandages of the body. 
Crossed Bandages. 

Posterior figure of 8 of the head and axillas. 

Anterior figure of 8 of the head and axillas. 

Figure of 8 of the head and one axilla. 

Figure of 8 of the neck and axilla. 

The spica or figure of 8 of the shoulder and opposite axilla. 

The anterior figure of 8 of the shoulders. 

The posterior figure of 8 of the shoulders. 

The crossed bandage of the chest. 

The crossed bandage of one breast. 

The crossed bandage of both breasts. 

The crossed bandage of one groin. 

The crossed bandage of both groins. 

COMPOUND BANDAGES. 
T Bandages. 

The double T of the chest and abdomen. 

The anterior double T of the head and chest. 

The posterior double T of the head and chest. 

The double T of the pelvis. 

The T bandage of the groin. 
The Crossed Bandage of the Trunk. 
Sling Bandages. 

The sling bandage of the shoulder. 

The sling bandage of the breast. 

The sling bandage of the hip. 
Suspensory Bandages. 

The suspensory of the breast. 

The suspensory of the testicle. 
Sheath Bandages. 

The sheath of the penis. 

MAYOR'S BANDAGES FOR THE NECK AND TRUNK. 

The cravat of the neck. 

The occipito-thoracic triangle. 

The fronto-thoracic triangle. 

The parieto-axillary triangle. 

The thoracico-scapular triangle. 

The simple bis-axillary cravat. 

The compound bis-axillary cravat. 

The simple dorso-bis-axillary cravat. 

The compound dorso-bis-axillary cravat. 

The cravat, triangle, and squares. 

The triangular cap of the breast. 

The cervico-thoracic cravat. 

The cervico-dorso-sternal cravat. 

The sacro-pubic triangle. 

The intercrural cravat. 

The cruro-pelvic triangle. 



176 

The cruro-pelvic cravat. 
The sacro-bi-crural cravats. 
The sacro-lumbar triangle. 
The coxo-pelvic triangle. 

RIGAL'S BANDAGES FOR THE NECK AND TRUNK. 

The cervico-axillary cravat. 

The lateral thoracic bandage. 

The sternal triangle. 

The dorsal triangle. 

The thoracico-abdominal bandage. 

The girdle. 

A. Simple Bandages. 
§ 1. Circular Bandages. 

Circulae Bandage of the Neck. Composition. — A roller a yard 
and a quarter long and an inch and a half or two inches wide. 

Application. — Confine the initial extremity upon the neck by a cir- 
cular turn, and finish the bandage by exhausting the roller. 

Use. — An extremely simple mode of keeping dressings upon the 
neck. Care should be taken not to constrict the neck in such a man- 
ner as to interrupt the circulation in the bloodvessels of that part or 
interfere with the respiration. 

Circular Bandage of the Body. Composition. — A piece of mus- 
lin of more than sufficient length to go around the body, and from a 
foot to a foot and a half wide. If the bandage is to be applied to the 
chest (circular bandage of the chest) place the body of the piece of 
muslin upon the back and bring its ends to the front, then overlap 
and pin them. 

On the contrary, if the abdomen is to be bandaged, place the middle 
portion of it upon the loins (circular bandage of the abdomen). In 
order to prevent these bandages slipping up or down, two small strips 
of muslin are sometimes attached to their upper and lower edges, pass- 
ing over the shoulder and under the perineum. 

An abdominal bandage may be prepared which will retain its place 
without the aid of scapular or perineal strips. It consists of a piece 
of muslin with gores made in its lower margin and fitting over the 
hips, the bandage being prevented from wrinkling by four pieces of 
very flexible whalebone inserted vertically at the sides and front. Its 
anterior edges are perforated with eyelet holes to receive the lacing 
cord. 

Other more complicated abdominal supporters are often recom- 
mended, but this one will answer every purpose, and may be made in 
a few minutes in any household. 

Use. — The circular bandage of the chest is used to insure immo- 
bility of the walls of the chest in fractures of the bones composing it. 
The abdominal bandage serves the purpose of supporting the walls of 
the abdomen in pregnancy, after confinement, and the operation of 
paracentesis. 



OBLIQUE BANDAGES. — FIGURE OF 8 BANDAGES. 177 

§ 2. Oblique Bandages. 

The Oblique Bandage of the Neck and Axilla. — 1st Variety. 

Composition. — A roller bandage six yards long and two inches wide. 

Application. — Place the initial extremity of the bandage upon the 
shoulder of the healthy side, and confine it by a circular turn passing 
across the chest under the axilla and across the back to the point of 
starting. The bandage is finished when the roller shall have been 
exhausted by these turns. 

Use. — As a retentive bandage for the axilla, but it is badly adapted 
for this purpose, for the reason that the turns under the arm become 
corded, and they are apt to gall a tender surface. 

2d Variety ; the oblique bandage of the neck and axilla, for venesection 
at the external jugular vein. 

Composition. — 1st. A bandelette four yards long by two inches 
wide. 2d. A prismatically graduated compress about three inches 
long by two inches broad at its base. 

Application. — Place the compress over the external jugular vein 
just above the clavicle, and over this place that portion of the body 
of the bandelette about two feet from its extremity, the shorter end 
hanging obliquely across the chest ; carry the longer one over the 
shoulder corresponding to the vein from which blood is to be taken, 
across the back to the opposite axilla, under which it passes to cross 
the compress and shoulder to return again to the axilla. Now draw 
the two extremities of the bandage moderately tight, until the external 
jugular bulges sufficiently to be opened, and then tie them together. 

Use. — Only in venesection at the neck; 

§ 3. Spiral Bandages. 

Spiral Bandage of the Body — Spiral Bandage of the Tho- 
rax. Composition. — A roller ten yards long and two inches wide. 

Application. — Let a yard and a half of the free extremity of the 
bandage hang down from the right shoulder in front of the abdomen, 
then carry the roller across the back under the left axilla, in front of 
the chest so as to make a circular turn of the thorax, and continue in 
this manner descending, each turn overlapping a third or half of its 
predecessor, towards the abdomen, until the bandage is exhausted ; 
pin its terminal extremity. The free portion is now to be reflected 
over the left shoulder, and fastened behind with pins. 

Use. — To retain dressings upon the chest, and to make compression 
in fracture of the ribs. In the latter case suitable compresses are 
to be employed, of which two are to be placed upon either side of the 
line of fracture if the fragments form a salient angle, and at the ex- 
tremities of the rib if it is re-entrant. 

§ 4. Figure of 8 Bandages. 

The Posterior Figure of 8 of the Head and Axillas. Com- 
position. — A roller ten yards long and two and a half inches wide. 

Application. — Confine the initial extremity of the bandage by two 
circular turns at any point of the circumference of the head, which is 



178 SPECIAL, OR REGIONAL BANDAGING. 

drawn backwards as far as desired; when the roller comes to the 
mastoid process of the left side, conduct it obliquely across the neck 
and right scapula, and under the corresponding axilla, in front of which 
you must ascend to the point of departure ; from whence the roller 
passes around the forehead to the mastoid process of the opposite side, 
across the neck to the left axilla, under and in front of this to return 
to the neighborhood of the right ear, when the head is to be surrounded 
by a circular turn to confine the first two oblique turns. Eepeat this 
course again, and terminate the bandage by a circular turn around the 
forehead. 

Use. — This is called the anterior dividing bandage, and is used to 
retain the head in a position of more or less forced extension in burns 
of the front of the neck, when we fear distortion from excessive con- 
traction of the cicatrix drawing the head forward. The bandage is 
easily deranged, and not so advantageous for this purpose as others, 
to be described further on. 

It should be mentioned here, that in all of those bandages which 
have their turns passing under the axilla, the sharp margins of the 
latter, formed by the projection of the pectoralis major and the latissi- 
mus dorsi, should be protected by suitable compresses. 

The Anterior Figure of 8 of the Head and Axillas. — This 
bandage is applied in the same manner as the preceding, only re- 
versing it ; the crosses, which are upon the back of the neck in the 
former, are in front in the latter. 

Use. — The posterior dividing bandage is used for similar purposes 
as the preceding, when the injury is situated upon the nape of the 
neck, but it is exceedingly annoying to the patient by the crossings of 
its turns upon his face, at the same time being less effective than other 
dividing bandages to be mentioned presently. 

The Figure of 8 of the Head and Axilla. Composition. — A 
roller seven yards long by an inch and a half wide. 

Application. — Incline the head at the desired angle upon one or the 
other side, and confine the initial extremity of the bandage upon the 
head by two circular turns; then pass from the occiput in front of the 
shoulder to which the head leans, under the axilla, up over its poste- 
rior surface, to a point just above the nearest eyebrow ; make a reverse 
here, in order to pass horizontally around to the nape of the neck, 
thence conduct the roller in front of and under the axilla to the fore- 
head, where another reverse is made over the previous one ; repeat 
these turns three or four times, and terminate the bandage by circular 
turns around the upper part of the arm. Secure the reverses with 
pins. 

Use. — To bind the head to one side in order to counteract the con- 
traction of a cicatrix upon the opposite side of the neck, acting thus 
as a right or left dividing bandage of the neck, according as the head 
is drawn to the left or right side ; also as a uniting bandage for the 
side of the neck to which the head is inclined. 

The Figure of 8 of the Neck and Axilla. Composition. — A 
roller five yards long and two inches wide. 

Application. — Place the initial end of the bandage upon the neck 



SPICA OF SHOULDER AXD OPPOSITE AXILLA, 



179 



Fig. 119. 



and secure it by two circular turns, and then, if the object is to cover 
in the right axilla, conduct the bandage in front of the neck, from left 
to right, over the right shoulder, to the posterior part of the axilla, 
under which it passes to ascend in front of the same shoulder to the 
nape of the neck ; from this point pass around the neck and go over 
the same course three times, and terminate by two circular turns 
around the upper part of the arm. When the bandage is applied 
upon the left side, the roller must pass from right to left. It may also 
be executed with a double-headed roller, in which case the body is 
placed under the axilla, one of the cylinders is conducted in front and 
the other behind the shoulder to its top, where a cross is made ; then 
the former passes behind the neck and the latter in front of it, to meet 
each other in opposite directions upon its opposite side. The rollers 
are to be again crossed over the shoulder, conducted beneath the 
axilla, and the same process repeated three or four times. 

Use. — To support dressings upon the shoulder and in the axilla. 
The bandage is not very firm, and its turns cord in the axilla, and 
therefore it is unsuitable as a retentive means of topical applications 
in this region. 

The Spica or Figure of 8 of the Shoulder and Opposite Axilla. 
(Fig. 119.) Composition. — A roller 
eight yards long and two inches wide. 

Application. — Confine the initial ex- 
tremity to the upper part of the arm 
by two circular -turns, and when the 
roller arrives at the posterior margin 
of the axilla, conduct it behind the 
shoulder, over the root of the neck, 
across the front of the chest to pass 
under the opposite axilla, and oblique- 
ly across the back to the top of the 
shoulder again, where it crosses the 
previous turn. From this point the 
cylinder goes under the axilla, and 
over the same course as before, until 
five or six turns are made, or as many 
as will cover the shoulder from the 
root of the neck to the point of the 
acromion. In this manner one cross 
follows another from above down- 
wards, when the spica is said to be 
descending; when they proceed in the 
reverse direction, the spica is said to 
be ascending; the former making a firmer and neater spica. The 
terminal extremity of the bandage may be fixed with a pin in front 
or behind, or secured in the manner shown in the figure. It may also 
be executed with a double-headed roller, by placing its body under 
the axilla, crossing the two cylinders above the corresponding shoulder, 
and conducting them around the chest in opposite directions to the 
axilla of the opposite side, where they pass each other to be brought 




The spica of the shoulder. 



180 



SPECIAL, OR REGIONAL BANDAGING. 



Fig. 120. 



back to and crossed over the injured shoulder, and then passed under 
the corresponding axilla. Kepeat these turns until the bandage is 
exhausted. 

Use. — To retain dressings or apparatus upon the shoulder, clavicle, 
and scapular region, as well as to make pressure upon the former. 

The Anterior Figure of 8 of the Shoulders. Composition.— 
A roller rive yards long by two inches wide. 

Application. — Direct an assistant to draw the shoulders strongly 
forward, and to retain them in this position during the application of 
the bandage. Confine the initial extremity of the bandage to the 
upper part of the right arm, passing from before backwards, ascend 

behind the right shoulder and 
cross over it and the front of 
the chest obliquely to the left 
axilla, pass up the posterior 
surface of the shoulder to its 
top, when the roller takes a 
course obliquely across the 
chest to the right axilla, the 
two turns making a figure X 
over the sternum. Bepeat 
these turns in this manner 
three or four times and pin 
the terminal end of the band- 
age to them either in front or 
behind. 

Use. — To prevent the forma- 
tion of vicious cicatrices upon 
the back of the shoulder; to ap- 
proximate the lips of wounds 
upon 'the anterior and upper 
parts of the chest ; in fracture 
of the upper part of the ster- 
num; and to maintain the 
reduction of the inner extremity of the clavicle dislocated forwards. 

The Posterior Figure of 8 of the Shoulders. Composition. — 
A roller five yards long by two inches wide. 

Application. — The patient being seated upon a chair, the shoulders 
are well drawn back. Confine the initial extremity of the bandage to 
the upper part of the right arm, passing from behind forwards in the 
axilla, ascend in front of the right shoulder to the root of the neck, 
then cross the back of the chest obliquely to the left axilla under it 
and in front of the left shoulder, over its top, and thence diagonally 
across the back, the turns crossing each other, to the right axilla. 
Repeat this course three times and terminate the bandage by pinning 
the terminal end behind. 

The Crossed Bandage of the Chest. Composition. — A roller 
eight yards long and two inches wide. 

Application. — Place the initial extremity of the bandage under the 
right axilla and conduct the roller obliquely upwards across the chest 




The anterior figure of 8 of the shoulders. 



THE CROSSED BANDAGE OF BOTH BREASTS. 181 

to the top of the left shoulder ; pass behind this, and beneath the 
axilla up in front of the chest to the root of the neck ; then go ob- 
liquely across the back of the thorax to the right axilla ; under this 
to the front, and upwards to the right side of the neck. From this 
point the roller takes its course obliquely downwards across the back 
of the chest to the left axilla, under which it passes to the front to 
cross the chest to the right shoulder, behind which it passes, and under 
the right axilla ; thence upwards to the top of the left shoulder behind 
which the cylinder courses under the axilla to the front, and upwards 
to the root of the neck, around the posterior surface of this part to the 
right shoulder and axilla, under which it passes to gain the top of the 
same shoulder, and to cross the chest obliquely to the left axilla ; from 
this point the bandage is completed by three or four circular turns 
around the lower portion of the chest. 

A firmer quadriga may be made with a double-headed roller 
wound in two unequal cylinders. Place its body under the right 
axilla, conduct the two cylinders to the top of the right shoulder, 
where they are crossed, and continued to the left axilla, one in front 
the other behind the chest, under which they are again crossed, and 
carried to the top of the left shoulder to be crossed and finally brought 
to the right axilla. Eepeat this course two or three times, and termi- 
nate the bandage as in the former instance. 

Use. — As a retentive bandage in fracture of the ribs, upper part of 
the sternum, and dorsal vertebrae. It is rarely ever used, however, 
its place having been usurped by the spiral or circular bandage of the 
chest, and by long, broad strips of adhesive plaster laid over the chest 
circularly. 

The Crossed Bandage of One Breast. Composition. — A roller 
eight yards long by two inches wide. 

Application. — Confine the initial extremity of the roller under the 
diseased mamma, the left, for instance, by two circular turns, passing 
from left to right ; at the end of the third turn direct the roller ob- 
liquely between the two breasts to the middle of the top of the right 
shoulder, descend across the back to the left side, and make a circular 
turn of the chest to hold the oblique one, then ascend to the right 
shoulder as before. Make a sufficient number of turns in this manner 
to cover in and support the mamma, and terminate the bandage by a 
circular turn around the chest above or below that organ according 
to the circumstances of the case. 

Use. — To support and retain topical applications to the mamma, and 
at the same time make some degree of compression. 

This bandage may be advantageously supplanted by the single sling 
of the breast, to be described hereafter, and especially when it is neces- 
sary to renew the dressings frequently. 

The Crossed Bandage of Both Breasts. Composition. — A roller 
bandage twelve yards long by two inches wide. 

Application.— GonfmQ the initial extremity of the roller upon the 
lower part of the chest by three circular turns passing from right to 
left ; when the roller in the third turn arrives at the right side conduct 
it obliquely upwards between the breasts to the middle of the top of 



182 SPECIAL, OR REGIONAL BANDAGING. 

the left shoulder, thence down the back to the point of departure at the 
right side, then continue it transversely around the thorax to the left 
side, obliquely upwards over the back to the right shoulder ; down in 
front of the chest under the left mamma, transversely across the body, 
around the right side and upwards again between the breasts to the 
left shoulder ; cross the back to the right side, and make a horizontal 
turn under the chest to the right shoulder, descend under the left mam- 
ma and transversely around the posterior surface to the right side. In 
this manner make in all four or five crosses upon the sternum, or un- 
til both breasts are covered in, and terminate the bandage by circular 
turns around the body. 

A double-headed roller of the same length as the preceding, and 
wound in two unequal cylinders, may also be employed in making the 
double cross of both breasts. 

Place the body of the roller upon the middle of the lower and posterior 
part of the thorax, bring the two cylinders forward and cross them be- 
tween the two mammae, when one of them is to be carried over the right 
shoulder and the other over the left, and crossed on the back ; repeat this 
course a second time ; then, holding one of the cylinders at the back, 
conduct the longer one around the chest circularly to confine the two 
oblique turns. Bring both of the cylinders forward again, one pass- 
ing under each breast. Cross them over the sternum, and donduct 
them one over either shoulder, when another circular turn is to be 
made as before. Alternate these oblique and circular turns until the 
bandage is exhausted, and secure the terminal end with pins. 

Use. — Employed in the similar cases as the crossed bandage of one 
breast, when both mammas are diseased. 

The Crossed Bandage of the Groin (Spica). Composition. — A 
roller seven yards long and two inches wide. 

Application. — Place the initial extremity of the bandage upon the 
abdomen, just above the umbilicus, and confine it by two or three 
circular turns, passing from left to right if the right groin is to be 
covered in, and the reverse if the left. When the roller arrives at 
the right flank, carry it obliquely across the upper part of the groin 
to the perineum, going between the right thigh and scrotum ; then 
around the gluteal muscles to the point just above the right superior 
spinous process, where the roller is conducted across the abdomen to 
the left side, and around the loins to the right side again, when the 
same process is gone over again seven or eight times, or until the 
groin is covered in; each turn covering half of its predecessor and 
placed below it; terminate the bandage by circular turns around the 
abdomen. Made in this manner, the spica is said to be " descending;" 
and on the contrary, when the turns overlap each other from below 
upwards, it is " ascending." A double-headed roller may also be used 
by placing its body upon the loins, conducting the two cylinders for- 
wards, one around either side, crossing them over the groin, and 
afterwards behind the upper part of the thigh, when they are brought 
forwards again and crossed. Continue this process until the bandage 
is exhausted. 

Use. — To sustain dressings upon the groin, and also to make pres- 



COMPOUND BANDAGES. 183 

sure in cases of abscess, sinus, and hernial protrusions, the proper 
compresses having been previously applied over the parts. 

The Double Spica, or Crossed Bandage of Both Groins. 
Composition. — A roller twelve yards long and two inches wide. 

Application. — Place the initial extremity in the same position as 
for the single spica, and retain it by three circular turns around the 
abdomen, passing from right to left. When the roller comes to the 
right side, conduct it obliquely across the abdomen just above the 
penis to the outer side of the left thigh below the trochanter; pass 
over the back of the limb to its inner side, and ascend upwards 
towards the left anterior spinous process, crossing the previous turn 
below the groin. From this point, carry the cylinders to the corre- 
sponding process upon the right side, across the loins, down in front 
of the right groin, around the upper part of the right thigh, and in 
front to cross the previous turn, and ascend to the left flank around 
the back to the right side, the point at which the first oblique turn 
began. Go over this course three or four times, making an ascending 
spica, and terminate by circular turns around the abdomen. 

The same bandage may be executed with a double-headed roller : 
place its body upon the loins and make two circular turns around the 
abdomen, then bring the cylinders forwards, cross them over the 
pubis, conducting one of them around the outer surface of the right 
thigh and the other around the left, to the front, passing between the 
scrotum and thighs; then cross the previous turns over the' groins, 
when the cylinders should be led to the point of starting upon the 
loins. The same manoeuvre is to be repeated as often as necessary to 
cover both groins. 

Use. — In similar cases as the single spica, when the disease is 
seated upon both groins. 

B. Compound Bandages. 
§ 1. The Double T of the Body. 

The Double T of the Chest. Composition. — A piece of muslin 
the depth of the chest, and of sufficient length to entirely surround 
the body and overlap three or four inches, and two pieces of muslin, 
each two feet long and two inches wide. 

Application. — Place the body of the bandage upon the back of the 
thorax, bring its two ends forwards, overlap them, and pin. To pre- 
vent the bandage slipping down, the two bandelettes, passing one over 
each shoulder, are pinned to its superior margin. 

The Double T of the Abdomen. Composition. — The same as the 
preceding bandage. 

Application. — The body of the bandage is placed over the loins, and 
its ends brought forwards over the abdomen, and pinned. The two 
straps are conducted beneath the perineum and fastened to the lower 
margin of the bandage. 

Use. — The double T of the chest is used to retain dressings upon 
the upper portion of the body, and to restrain the movements of the 
chest in fracture of the ribs. 



184 SPECIAL OR REGIONAL BANDAGING. 

The double T of the abdomen is employed to maintain topical reme- 
dies upon the lower portion of the body, and also to make compres- 
sion, as after the operation of paracentesis abdominis and accouchement, 
and to prevent the displacement of the bowels in eventration. 

The Anterior Double T of the Head and Chest. Composition. 
— 1st. A double T bandage of the chest. 2d. Four bandelettes, one 
four yards long and two inches wide, to the superior border of which 
is sewed a second bandelette two feet long and of the same width, and 
to its lower border the ends of the other two bandelettes, each a foot 
and a half long and one inch wide, one fifteen and the other twenty 
inches from the initial extremity ; the superior bandelette being be- 
tween them. 

Application. — First fix the bandage to the thorax, then place the 
initial extremity of the long arm of the bandelette over the right eye- 
brow and confine it by a circular turn, bringing the superior bande- 
lette over the forehead in the median line. The latter is now to be 
conducted to the occiput, looped around the circular turn, and brought 
forward again and pinned over the top of the head, when other circu- 
lar turns are made until the band is exhausted. Now flex the head 
to the required angle, and hold it in that position by pinning the two 
strips hanging down from either side of the head upon the chest band- 
age. 

Use. — Used as a uniting bandage of wounds of the anterior portion 
of the neck, and as a dividing bandage in burns upon the posterior 
surface of the same part. 

The Posterior Double T of the Head and Chest. — This band- 
age is applied in the same manner except that the two vertical pieces 
of muslin should descend the back. 

Use. — To draw the head backwards, and is used under exactly the 
reverse circumstances of the anterior double T. 

The Double T of the Pelvis. Composition. — An oblong piece of 
muslin, folded upon itself, about four inches wide, and sufficiently 
long to more than complete the circuit of the pelvis by three or four 
inches. To the middle of its inferior margin sew two strips of muslin, 
one inch wide and a yard long, at a distance of one inch and a half 
apart. 

Application. — Place the body of the bandage over the sacrum so 
that the two strips may hang down behind opposite the scrotum, bring 
its lateral ends forward, overlap, and pin them securely ; then conduct 
the two bandelettes between the legs, one upon each side of the scro- 
tum, and pin them to the bandage in front. Where only one strip of 
muslin is employed, the single T is formed. 

Use. — To maintain dressings upon the sacrum, anus, perineum, and 
vulva. 

The T Bandage of the Groin (Fig. 121). Composition. — A triangu- 
lar piece of muslin of sufficient size to cover in the groin and to extend 
to the middle of the thigh. To one angle of its base sew the end of a strip 
of muslin two and a half yards long and an inch and a half wide; to the 
other a strip of the same width and four yards long. To the apex 



SLIXG BANDAGES. 



185 




The T bandage of the groin. 



of the triangle is attached the middle Fi S- 121 « 

of a third strip, a yard loog and of 
the same width as the preceding. 

Application. — Place the base of the 
triangle just above Poupart's liga- 
ment with that ansrle of the base to 

o 

which the long bandelette is attached 
looking towards the healthy side, for 
instance, the left; then carry the 
band of the outer ano-le around the 
left hip, across the small of the back, 
and in front of the lower portion of 
the abdomen to the rloint of depar- 
ture ; let it be held there until the 
band connected to the inner angle 
shall have been carried around the 
right hip obliquely across the sacrum 
to the outer part of the left thigh, 
around which it passes in front upon 
the triangle to the right flank, and 
across the back to the left flank, 

when the two ends are to be tied together. The apex of the triangle 
is fixed by a circular turn around the middle of the thigh. 

Use. — To hold dressings upon the groin, but it is inefficient when 
the patient moves around. 

§ 2. The Crossed Bandage of the Trunk. 

This bandage is very similar to the T bandage of the trunk, and is 
composed of a broad piece of muslin to go around the chest and over- 
lap three inches, with two straps attached to its superior border which 
pass over the shoulders, and two to its inferior margin passing under 
the perineum. It may be similarly applied to the abdomen. 

Use. — The cross bandage of the trunk is used under similar circum- 
stances as the double T bandages of the same part. 

§ 3. Sling Bandages. 

The Slixg Baxdage of the Shouldek. Composition. — A piece 
of muslin eight or ten inches wide and two yards and half long, split 
from each end into two tails. 

Application. — Place the body of the bandage over the shoulder, con- 
duct its superior tails, one in front and the other behind the chest, to 
the opposite axilla, cross them here, and bring them back to the 
shoulder and tie them ; the inferior ones are exhausted by circular 
turns around the upper part of the arm. 

Use. — This bandage is used to support dressings upon the shoulder ; 
but it is not very firm. 

The Slixg Baxdage of the Breast. Composition. — A piece of 
muslin eight or twelve inches square, having sewed to one of its sides 
a muslin strip three yards long and two inches wide, and to each of its 
opposite angles a narrow strip an inch and a half wide and a yard long. 



186 



SPECIAL, OR REGIONAL BANDAGING. 



Application. — Place the square piece of muslin over the breast, with 
the broad band horizontal, the two ends of which latter are now to be 
carried around the chest beneath the mammae, crossed upon the back, 
brought forward and pinned in front. The two narrow strips are 
passed around the neck, one upon either side, to its back part over 
which they are tied in a bow knot. 

Use. — To support the breast, and to sustain poultices or other dress- 
ings in place. 

The Sling Bandage of the Hip. Composition. — A piece of mus- 
lin two yards and a half long and eight or ten inches wide, split at 
each end in two parts. 

Application. — Place the body of the bandage over the hip, conduct 
its superior extremities around the loins, cross them there, and finally 
tie them on the same side on which the bandage is. The two extremi- 
ties are to be fastened by a knot around the upper part of the thigh. 

Use. — To retain dressings over the hip. 

§ 4. Suspensory Bandages. 

The Suspensory Bandage of the Breast. Composition. — A 
piece of muslin about eight inches wide and nine inches long ; fold it 
upon itself lengthwise and remove with the scissors the angles adjoin- 
ing the folded border, and sew the edges thus made together. To the 
two upper angles attach two bandelettes one inch wide and a foot and 
a half long, and to the inferior angles two or more of similar width 
but a yard and a quarter long. 

Application. — Place this sort of cap-like piece of muslin over the 
diseased mamma, carry the superior bandelettes around the neck, and 
tie them behind it, and the inferior ones around the chest ; cross them 
over the posterior surface of the chest, and finally bring the ends 
forward again to be tied or pinned in front. 

Use. — To support the mamma when large and pendulous, and to 
retain topical dressings upon the part. 

The Suspensory Bandage of the Scrotum. Composition. — A piece 
of muslin (Fig. 122), whose size will vary according to the volume of the 

testicles, must be taken ; for or- 
Fl S- 122, Fl &* 123, dinary use, six inches wide and 

eight inches long will answer; 
fold it in the direction of its 
length, and with the scissors, 
remove the angles (a c?and b a) 
in the direction of the dotted 
lines, sew the edges together 
along the line (a, b), and also 
sew to the angles (6) the ex- 
tremities of two pieces of mus- 
lin one inch wide by two feet 
long, each having a button-hole 
worked in the free end. At- 

The suspensory bandage of the scrotum. tach the tWO borders (c, d) tO 





mayor's bandages for the trunk. 187 

the middle of a muslin strip doubled upon itself and sewed together 
to make a sort of belt, an inch wide and two yards and a half long, 
with a button near each free extremity. 

Application. — Introduce the scrotum, covered with its dressings, 
into the suspensory, with the penis projecting out of the aperture in 
front, carry the horizontal bands arouud 
the pelvis, cross them behind, and finally 
bring them to the front, and fasten the 
extremities over the pubis with a pin or 
button. The two other strips are conducted 
behind, around the upper portion of the 
thigh, one upon each side, and are buttoned 
over the groins, as seen in Fig. 123. 

A very elegant suspensory is supplied by 
the shops, manufactured by weaving together 
cotton or silk threads, either alone or with 

n .. ' . Elastic suspensory bandage. 

caoutchouc threads, (rig. 124.) 

Use. — To support the scrotum, in orchitis ; varicocele; and irredu- 
cible hernias. 

§ 5. Sheath Bandages. 

The Sheath of the Penis. Composition. — A sheath of muslin large 
enough to hold the penis is made, and to its base two strips of muslin 
are to be sewed sufficiently long to reach around the body. Cut a 
small hole in its apex to permit the passage of the urine. 

Application. — Place the necessary dressings upon the penis and slip 
the sheath over them, conduct the two strips around the pelvis and 
knot them behind. 

Use. — To sustain the penis upon the abdomen during inflammatory 
affections of that organ, and also to retain dressings upon it. 

C. Mayor's Bandages for the Trunk. 

The Cravat of the Neck. Composition. — A triangular piece of 
muslin folded in a cravat. 

Application. — Place the body of the cravat upon any part of the 
neck, cross the lateral extremities upon the opposite side, and finally 
bring them back and knot them together. Mayor recommends the 
insertion of a piece of stiff paper in the folds of the triangle, or when 
suppuration is profuse, light wire gauze, to prevent the cravat's 
wrinkling. 

Use. — To confine dressings upon the neck. 

The Occipito-Thoracic Triangle (Occipito-Sternal). Com- 
position. — Two triangular pieces of muslin, a yard and a quarter long- 
by eighteen inches from the middle of the base to the apex; one is to 
be folded in a cravat. 

Application. — Place the body of the cravat over the sternum and 
tie its lateral ends behind the back. The base of the triangle is now 
placed over the occiput, and its two extremities fastened in front to 
the sternal cravat after the head has been flexed to the necessary 



188 



SPECIAL OR REGIONAL BANDAGING. 



extent ; the apex is to be carried over and pinned upon either side of 
the bandage. 

Use. — As a substitute for the flexor bandages of the head already 
described. 

The Fronto-Thoracic Triangle (Fronto-Sternal). — The only 
difference between the mode of applying this bandage and the pre- 
ceding is that the base of the triangle should be placed upon the fore- 
head instead of the occiput, and its tails tied to the cravat behind. 

Use. — As a substitute for the extensor bandage of the head already 
mentioned. 

The Parieto-Axillary Triangle. Composition. — A triangular 
piece of muslin a yard and a quarter long and eighteen inches from 
base to apex. 

Application. — Place the base of the triangle upon the parietal emi- 
nence on either side, carry the lateral angles under the opposite axilla, 
where they are to be tied, or else to a cravat, which has been prelimi- 
narily knotted around the shoulder of that side. The apex may be 
conducted around the head and pinned over either temple. 

Use. — To bend the head to one side or the other, and to replace the 
figure of 8 bandage of the head and axilla. 

The Thoracico-Scapular Triangle. Composition. — A triangular 
piece of muslin a yard and a quarter long and eighteen inches from 
base to apex. 

Application. — Place the base of the triangle beneath the part to 
which the dressings are applied either upon the anterior or posterior 
aspect of the chest, conduct its extremities to the opposite side, and 
tie them. The apex may be carried over the right or left shoulder, 
and connected, by lengthening it if necessary, with one of the ex- 
tremities of the bandage. 

The Simple Bis- Axillary Cravat (Fig. 125). Composition. — A 

piece of muslin a yard and 
Fig. 125. a quarter long and eigh- 

teen inches deep, folded in 
a cravat. 

Application. — Place the 
body of the bandage upon 
the diseased axilla after the 
dressings have been ap- 
plied ; the lateral extremi- 
ties should then be crossed 
over the shoulder of the 
same side, and carried one 
behind and the other in 
front of the chest to the 
opposite axilla, where they 
are to be tied. 

Use. — To retain dressings upon the axilla and to replace the reten- 
tive bandages of this region. 

The Compound Bis- Axillary Cravat. Composition. — Two cravats 
a yard and a quarter long. 




Simple bis-axillary cravat. 



mayor's bandages for the trunk. 189 

Application. — Place the body of one of the cravats upon one of the 
axillae, and tie its extremities over the corresponding shoulder. The 
body of the other cravat is laid over the other axilla, and its extremi- 
ties are carried one over the front, and the other behind the chest, 
looped around the first cravat, and tied in front. 

Use. — To retain dressings upon both axillae. 

The Simple Dorso-bis-Axillary Cravat. Composition. — A cra- 
vat a yard and a half long. 

Application. — Place the body of the cravat between the shoulder- 
blades in an oblique direction so that one of its lateral extremities 
may pass over one shoulder and the other under the axilla of the op- 
posite side, then bring the former under the axilla and the latter over 
the shoulder, and tie them together over the back. 

Use. — To draw both shoulders backwards, thus fulfilling the same 
indications as the posterior figure of 8. 

The Compound Dorso-bis-Axillary Cravat. Comp>osition. — Two 
cravats a yard long. 

Application. — Place the body of one of the cravats in front of the 
left shoulder, and knot its extremities upon its opposite side, thus 
forming a kind of loose ring. The body of the other cravat is laid 
over the corresponding part of the right shoulder, and its extremities 
carried behind; the superior one looping around the cravat upon the 
opposite side, and the inferior extremity looping around the superior, 
when their ends are to be tied together. 

Use. — The same as the preceding. 

The Cravat. — Triangular and oblong pieces of muslin may also be 
employed to retain dressings upon the chest and abdomen, and to make 
compression ; their application is obvious. 

The Triangular Cap for the Breast. Composition. — A trian- 
gular piece of muslin a yard and a quarter long and eighteen inches 
deep. 

Application. — Place the base of the triangle beneath the suffering 
organ, carry one of its extremities under the corresponding axilla, and 
the other over the opposite shoulder, and tie them together behind ; 
the apex is conducted over the shoulder and pinned to the bandage 
behind. 

The Cervico-Thoracic Cravat. — A cravat a yard and a quarter 
long, with its base placed upon the nape of the neck, and its extremi- 
ties drawn down in front and pinned to a body bandage. It is princi- 
pally employed as a scapulary. 

The Cervico-dorso-sternal Cravat. Composition. — A triangle 
of muslin a yard and a quarter long and eighteen inches deep. 

Application. — Place its base upon the nape of the neck and bring its 
lateral extremities forward to be pinned to a body bandage, while its 
apex, hanging down the back, is fastened to the bandage behind. 

Use. — To confine dressings upon the back. 

The Sacro Pubic Triangle (Posterior Pelvic). Composition. — 
A triangle a yard and a quarter long and eighteen inches deep. 

Application. — Place the base of the triangle upon the loins, con- 
duct its extremities around the flanks, and tie them together in front 



190 



SPECIAL, OR REGIONAL BANDAGING. 



Fig. 126. 



of the abdomen. The apex is now to be brought forward under the 
perineum between the thighs, and pinned to the extremities. 

Use. — To retain dressings upon the posterior surface of the pelvis 
and perineum. 

The Intercrural Cravat. Composition. — Two cravats, each a 
yard long. 

Application. — Fasten one of them around the loins with pins, the 
body of the other cravat is placed over the perineum and its extre- 
mities brought upwards, one in front and the other behind the pelvis, 
and pinned to the first cravat. 

Use. — To maintain topical dressings upon the perineum, anus, and 

vulva, and intended to replace the double T bandage used for the same 

purpose. 

The Cruro-Pelvic Triangle ( Cruro-Inguinal ) (Fig. 126). 

Composition. — A triangle a yard and a half 

from one extremity to the other, and two feet 

deep. 

Application. — Place the base of the triangle 
obliquely across the groin ; for instance, the 
right one, conduct the superior extremity 
around the left side, across the loins to the 
right groin, where it is pinned to the band- 
age. The inferior end should be carried around 
the upper part of the right thigh between it 
and the scrotum, to a point near the superior 
extremity, and fastened with a pin. 

Use. — To keep dressings upon the groin, 
hip, and upper part of the thigh. 

The Cruro-Pelvic Cravat (Inguinal). 
Composition. — A cravat a yard and a half long. 
Application. — Place the body obliquely 
upon the diseased groin, we will say the right ; then conduct its upper 
extremity behind around the left side to the right hip and its inferior 
one downwards just above the penis, across the upper part of the thigh, 
between it and the scrotum to the right hip, where the two ends are to 
be knotted together. 

Use. — To maintain poultices and other dressings to the groin. 
The Sacro-bi-Crural Cravats. Composition. — Two cravats, each 
a yard and a quarter long. 

Application. — Knot one of the extremities of each cravat together ; 
then place this part of the bandage over the sacrum, and conduct each 
cravat around its corresponding side over both groins, backwards be- 
tween the scrotum and thigh, one upon either side and around the 
upper parts of the thighs ; the extremity of the right cravat should 
be pinned to the bandage over the groin of the left side, and that of 
the left cravat over the right groin. 

Use. — For the same purposes as the double spica. 
The Sacro-Lumbar Triangle (Suspensory) (Fig. 127). Compo- 
sition. — 1st. A triangle three-fourths of a yard long and a foot from its 
base to its apex. 2d. A cravat a yard long. 




The cruro-pelvic triangle 



rigal's bandages for the truxk. 



191 



Fig. 127. 




The sacro-lumbar triangle 



Application. — Surround the loins with the cravat, and then place 
the base of the triangle upon the back part of the scrotum ; conduct 
its two lateral extremities upwards, and form 
loops around the cravat, passing from before 
backwards, and bring them to the median 
line, passing outside of that portion of the 
triangles in contact with the scrotum, when 
they are to be knotted together. The apex is 
now drawn upwards over the scrotum and 
penis, slipped under the knot, and the cravat 
reflected upon itself, and pinned. 

Use. — This is used when a suspensory band- 
age is indicated. 

The Coxo-Pelvic Triaxgle. Composi- 
tion. — 1st. A triangle a yard and a quarter 
long and eighteen inches deep. 2d. A cravat 
a yard and a half long. 

Application. — Apply the cravat around the 
body just above the hips; then place the base 
of the triangle on the upper and posterior part of the thigh ; conduct its 
extremities around this, cross them upon the opposite side, beneath 
the perineum, and finally bring them back and tie them together over 
the posterior surface of the thigh. Now draw the apex of the triangle 
upwards, loop it around the cravat, and fasten it with a pin. 

Use. — To retain dressings upon the gluteal region. 

D. Eigal's Baxdages for the Trunk. 

The Cervico- Axillary Cravat. Composition. — A cravat a yard 
long, and an India-rubber ring. 

Application. — Place the body of the cravat upon the diseased axilla, 
and pass its extremities through the elastic ring over the opposite 
shoulder, when they are to be reflected upon themselves and tied 
together upon the opposite side of the neck. 

Use. — Used as a retentive dressing for the axilla. 

The Lateral Thoracic Baxdage. Composition. — A handkerchief 
folded in a triangle. 

Application. — Place the base of the triangle upon either the right or 
left side, over the false ribs ; conduct its extremities circularly around 
the body to a point exactly opposite, and pin them together. Draw 
the two angles of the apex, one in front and the other behind the chest, 
to the opposite shoulder, over which they are tied. 

Use. — This bandage covers in two-thirds of the chest, front and 
back, and is a ready means of retaining dressings upon extensive burns 
of that region. 

The Sterxal Triaxgle. Composition. — 1. A handkerchief or 
square piece of muslin folded in a triangle; 2. An elastic thread. 

Application. — Place the base of the triangle over the epigastrium, 
and carry its lateral angles around the body, and tie them upon its 
posterior surface ; then raise the apex of the triangle to the root of the 



192 SPECIAL, OE REGIONAL BANDAGING. 

neck, separate its angles, and conduct one upon either side of it to the 
nape of the neck, where they are to be knotted together ; now loop 
the middle of the elastic thread around the upper knot, conduct the 
two halves vertically to the lower knot, to which they are also fastened 
with a thread, then separate them that they may pass over the nates, 
under the perineum, and around the outer surface of the hips, to the 
posterior portion of the iliac crest, where each thread loops around its 
own portion ; they are finally brought forward again, one upon the 
right the other upon the left side, and fastened to the lower margin 
and middle of the base of the triangle. 

Use. — Employed for retaining dressings upon the whole anterior 
portion of the chest. 

The Dorsal Triangle. — This is applied in the same manner, only 
placing the triangle upon the posterior surface of the chest. 

Use. — As a retentive bandage for the posterior surface of the chest. 

The Thoracico- Abdominal Bandage. Composition. — A handker- 
chief folded in a triangle with the two angles of the apex truncated, 
and four elastic threads. 

Application. — Place the base of the triangle transversely across the 
middle portion of the trunk with the apex hanging downwards ; con- 
duct its lateral angles around the body and knot them together be- 
hind ; now raise the anterior angle to the top of the sternum, and sup- 
port it in that position by an elastic thread passing around the nape 
of the neck and fastened to its two corners. To each corner of the 
inferior angles elastic threads are attached, which pass backwards be- 
tween the thighs around the upper and outer surface of the hip, one 
upon each side, to be fastened to the bandage in front just above the 
groin. 

To prevent the elastic ring round the neck working up, a cord of 
the same material connects it vertically with the knot upon the middle 
line of the back. 

Use. — This bandage will serve very well to retain lint or other 
dressings upon burns of a large extent of the anterior surface of the 
body. 

The Girdle. Composition. — A cravat a yard and a quarter long, 
and an elastic ring. 

Application. — Place the body of the cravat upon the abdomen and 
conduct its extremities to the posterior surface of the body, where 
they are passed through the elastic ring, and are then brought forward 
again and pinned to the body of the cravat over the loins. 

Use. — To support the abdomen when pendulous. 



BANDAGES OF THE UPPER EXTREMITIES. 193 

SECTION III. 

BANDAGES OF THE UPPER EXTREMITIES. 

SIMPLE BANDAGES. 

Circular Bandages. 

The circular bandage of a finger. 

The circular bandage of the forearm. 

The circular bandage of the arm. 
Spiral Bandages. 

The spiral bandage of a finger. 

The spiral bandage of all the fingers (Gauntlet). 

The spiral bandage of the hand and fingers. 

The spiral bandage of the forearm. 

The spiral bandage of the arm. 

The spiral bandage of the whole arm. 
Figure of 8 Bandages. 

The figure of 8 bandage of the thumb and wrist. 

The posterior figure of 8 bandage of the hand and wrist. 

The anterior figure of 8 bandage of the hand and wrist. 

The figure of 8 bandage of the elbow. 

The extensor figure of 8 bandage of the hand and forearm. 

The flexor figure of 8 bandage of the hand and forearm. 
Recurrent Bandages. 

The recurrent bandage of a stump of the arm and forearm. 

The recurrent bandage after disarticulation at the shoulder. 
Bandages. 

The large quadrilateral scarf of the arm and chest. 

The oblique quadrilateral scarf of the arm and chest. 

The scarf of the arm and neck. 

The scarf of the hand and forearm. 

COMPOUND BANDAGES. 
T Bandages. 

The simple T bandage of the hand. 

The double T bandage of the hand. 

The perforated T bandage of the hand. 
Sling Bandages. 

The sling bandage of the hand. 

The anterior sling bandage of the elbow. 

The posterior sling bandage of the elbow. 
Sheath Bandages. 

The sheath bandage of the fingers. 
Laced and Buckle Bandages. 

The laced bandage of the arm. 

The laced bandage of the body (strait jacket). 

MAYORS BANDAGES OF THE UPPER EXTREMITIES. 
Cravats, triangles, and squares. 
The carpo-digito dorsal triangle. 
The interdigital triangle. 
The palmo-digito-brachial triangle. 
The carpo-olecranon cravat. 
The carpo-cervical triangle. 
The cervico-brachial triangle. 
The triangular cap of the shoulder. 
The triangular cap of stumps. 

RIGALS BANDAGES OF THE UPPER EXTREMITIES. 

The deltoid bandage. 
13 



194 SPECIAL, OR REGIONAL BANDAGING. 

A. Simple Bandages. 
§ 1. Circular Bandages. 

The Circular Bandage of a Finger (Fig. 128). Composition. — 

A piece of muslin a yard 

Fi §- 128 « and a quarter long and 

^qr-rr—yT^ __^^ three-quarters of an inch 

/iwr^^^^' \ Application. — Permit a 

ftl l^^^fc^^^iSfe \ ^ ew inches of the initial 

/./ CJjSflf^^^ ilk N. extremity of the bande- 

^^vfr ^fli, if\ ^ et * e to rem ain free, ex- 

^ ^fljl^ W ll li/^ haust the balance of it by 

JK|j^ $< /v; circular turns around the 

4^^R5^\ vX finger, and knot the two 

'ly 'I I f ends together. Or when 

Circular bandage of a finger. the initial end is COn- 

fined, the terminal one 
should be split in two a few inches, and then carried around the finger 
in opposite directions and tied. A piece of thread will answer the 
same purpose of retaining the bandage. 

Use. — The common retentive bandage in popular use for injuries 
of the fingers. 

The Circular Bandage of the Forearm. Composition. — A 
bandelette a yard and a quarter long and one inch and a half to two 
inches wide. 

Application. — The initial extremity is confined to the wrist by a 
circular turn, and the bandage exhausted, when the terminal end may 
be fixed by any of the methods above mentioned. 

Use. — To confine dressings to a limited portion of the forearm, 

The Circular Bandage of the Arm. 1st Variety. 

The composition, mode of application, and use of this bandage are 
the same as the circular bandage of the forearm. 

2d Variety, for venesection. 

Composition. — A strip of muslin a yard and a quarter long by three 
inches wide, folded upon itself in the direction of its length. 

Application. — Let the patient be seated upon a chair opposite the 
surgeon, who supports the hand of that arm upon which the venesec- 
tion is to be performed, pressed against his chest; then take the body 
of the bandelette between the fingers of both hands, and place it about 
an inch above the point where the puncture is to be made, conduct 
its extremities backwards, cross them upon the posterior face of the 
limb and bring them forwards, when they are to be tied in a single 
bow-knot upon the outer margin of the arm. 

The amount of constriction should be sufficient to interrupt the 
return of blood in the vein, without arresting the pulsation in the 
radial artery ; for this would defeat the object in view by cutting off 
the supply of blood to the vein. 

Use. — This bandage is employed exclusively in venesection. 



SPIEAL BANDAGES. 



195 



Fig. 129. 



§ 2. Spiral Bandages. 

The Spieal Bandage of a Finger. Composition. — A strip of 
muslin a yard and a half long and three-quarters of an inch wide. 

Application. — If a finger of the right hand is to be bandaged, place 
it in a prone position ; then, permitting three or four inches of the 
initial extremity to hang free from the ulnar border of the wrist, make 
two circular turns around this part ; when the roller arrives at the 
fifth metacarpal articulation, cross the back of the hand obliquely to 
the radial margin of the base of the finger (the index, if you please), 
which is to be covered by spiral turns to its point ; and returning, 
these are inclosed by circular turns, each of which should overlap a 
half of its predecessor, until the ulnar border of the base of the finger 
is reached, when the roller passes obliquely across the back of the 
hand, crossing the previous turn, to the radial border of the first meta- 
carpal bone, and thence around to the ulnar border of the wrist, where 
the initial and terminal extremities of the bandage should be knotted 
together. 

Use. — To make compression upon the finger, and to retain dressings 
and splints upon it. 

The Spiral of the Fingers (the Gauntlet) (Fig. 129). Compo- 
sition. — A roller eight yards long and three-quarters of an inch wide. 

Application. — Place the hand in a position 
of pronation, and if the left hand is to be 
bandaged, let three or four inches of the 
initial extremities hang free from the radial 
border of the wrist ; then make two circular 
turns of this part, and when the roller 
arrives at the styloid process of the radius 
cod duct it obliquely across the hand to the 
ulnar margin of the base of the little finger, 
which is to be inclosed with spiral turns to 
its point ; returning, make circular turns, 
each of which ought to overlap half the 
width of its own predecessor, until the radial 
margin of its base is reached, when the rol- 
ler should be made to pass around the lower 
part of the ulnar border of the hand, across 
its palm to the radial border of the wrist; 
whence it again takes its departure to cross 
the back of the hand to the base of the ring 
finger, which is covered in the same man- 
ner as the previous one, and then the roller 
returns again around the ulnar border of the 
hand across the palm to the point of departure ; in this manner all the 
fingers are covered in, and the terminal end of the bandage tied to 
the initial end in a double bow-knot over the posterior surface of the 
wrist; or the bandage may be completed by circular turns around the 
hand, as seen in the figure. 

Use. — To prevent adhesions between the adjacent margins of the 




196 



SPECIAL, OR REGIONAL BANDAGING 



130. 




fingers during the healing process after burns ; to make pressure upon 
the hand and fingers, and as a retentive bandage in fractures and dis- 
locations of the phalanges. 

The Demi Gauntlet (Fig. 130). Composition. — A roller five yards 
long and three-quarters of an inch wide. 

Application. — The hand should be placed 
in the same position as in the previous case, 
and if it be the left one which is being band- 
aged, let two or three inches of the initial 
extremity of the roller hang free from the 
radial border of the wrist, which is encircled 
twice ; and when the cylinder arrives at this 
point again, at the end of the second turn it 
should be conducted obliquely across the 
dorsum of the hand to the ulnar margin of 
the base of the little finger ; then in front of 
this and around between it and the ring- 
finger to the ulnar margin of the hand; 
around this, across the palm, to the radial 
margin of the wrist, whence the roller 
crosses the dorsum of the hand to pass 
around the base of the ring-finger, and back 
again, as in the previous turns. In this man- 
ner, pass around the roots of all the fingers ; 
and finally, when the band is exhausted, knot 
its extremities together over the wrist. 
Use. — As a retentive bandage in disloca- 
tions of the first phalanges upon the metacarpal bones, and also to 
maintain dressings upon the back of the hand, for which purpose it 
is well adapted by its simplicity and lightness. 

The Spiral Bandage of the Fingers and the Hand. Com- 
position. — A roller four yards long and an inch and a half wide. 

Application. — Place the hand prone, and confine the initial extremity 
of the roller by two circular turns around the fingers ; proceed up- 
wards by circulars to the base of the thumb, where the irregularity of 
the parts will demand more or less reverses, which should be one above 
another in the median line of the hand ; terminate the bandage by 
two or three circular turns around the lower portion of the forearm, 
and pin the terminal end. 

Use. — To maintain in position apparatus for fracture of the bones 
of the hand, and to make pressure upon the parts. 

The Spiral of the Forearm. Composition. — A roller two yards 
and a half long and one inch and a half wide. 

Application. — Confine the initial extremity by circular turns around 
the wrist, then ascend the forearm, making the required number of 
reverses to permit the bandage to lie smoothly on the limb, and termi- 
nate by two or three circular turns around the lower portion of the 
arm. 

Use. — To support topical applications upon the forearm. 
The Spiral Bandage of the Arm. Composition. — A roller two 
yards and a half long and an inch and a half wide. 



The demi-gauntlet. 



CROSSED BANDAGES, 



197 



Fig. 131. 



43 



Application. — Confine the initial end below the elbow, and ascend 
the arm by circular and re'verse turns, until it is entirely inclosed to 
the axilla, when the bandage is terminated by circular turns. 

Use. — The same as the preceding. 

The Spiral Bandage of the Whole Arm (Fig. 131). Composi- 
tion. — A roller twelve j^ards long and an inch 
and a half wide. 

Application. — As the three preceding band- 
ages go to make up the spiral of the whole arm, 
or, in other words, are so many sections of it, 
there will be no necessity of describing it in 
detail. It is begun exactly as the spiral of 
the hand, and terminated as that of the arm. 
Care should be taken to make a sufficient 
number of reverses to enable the bandage to 
embrace the limb evenly and neatly. 

Use. — This bandage is often employed in 
treatment of fractures of the bones of the arm 
and forearm, to prevent engorgement of the 
extremity ; to make uniform pressure over a 
large extent of surface in inflammatory affec- 
tions of the skin and cellular tissues, as in 
erysipelas, and especially where there are large 
collections of pus, detaching the integuments 
from the subjacent parts; to arrest hemorrhage 
from wounded arteries ; or to retard the cur- 
rent of blood circulating through them in aneu- 
rismal cases; and, lastly, to retain dressings 
upon the whole extent of the limb after scalds 
and burns. 



§ 3. Crossed Bandages. 

The Crossed Bandage of the Thumb 
(The Spica). Composition. — A roller two 
yards and a half long and two-thirds of an 
inch wide. 

Application. — Let the hand be placed in a 
position of pronation, the right hand, for in- 
stance, then permit three or four inches of the 
free end of the roller to hang from the ulnar 
margins of the wrist, around which two or 
three circular turns are to be made ; arriving at 
the fifth carpo-metacarpal articulation, passing 
from the ulnar to the radial border, cross the 
back of the hand obliquely to the radial border 

of the second phalangeal articulation of the thumb, and in front of it, 
to its ulnar border, over its dorsum, crossing the previous turn at this 
point, then down around the radial border of the hand across the palm 
of the hand to its ulnar border, the point where the first oblique turn 



The spiral bandage of the whole 



198 SPECIAL, OE REGIONAL BANDAGING. 

began. In a similar manner make a sufficient number of these turns 
to cover in the thumb completely, each one of which should overlap half 
the width of its predecessor, forming an ascending spica. When the 
turns are made from the base towards the point of the thumb, the 
spica is said to be descending. Terminate the bandage by knotting 
the extremities together over the back of the wrist. 

Use. — To keep dressings upon the thumb, and to make compression 
in dislocation of the carpo-metacarpal articulation. This spica may 
be applied in a similar manner to any of the fingers. 

The Posterior Figure of 8 of the Hand and Wrist. Com- 
position. — A roller seven yards long and two inches wide. 

Application. — Let the hand be pronated, the left, for instance, then 
allowing three or four inches of the roller to hang free from the radial 
border of the wrist, make two circular turns about this part ; arriving 
at the first carpo-metacarpal articulation, pass obliquely across the 
hand to the base of the little finger, then across the palmar surface 
of the first phalanges, around the radial border of the index finger, 
and back transversely over the dorsal surface of the first phalanges ; 
thence around to the first metacarpo-phalangeal articulation, across the 
palmar surface again to the base of the index finger; now cross the 
dorsum of the hand obliquely to the ulnar margin of the wrist, 
making a cross with the previous turn over the metacarpal bones, 
around which one circular turn should be made, when the roller will 
arrive at the radial margin of the wrist — the point of departure. Go 
over this course once or twice more, and terminate the bandage by 
knotting the ends together at the wrist. 

Use. — For retaining dressings upon the posterior surface of the 
hand and to make compression upon that part after dislocation of the 
carpal and metacarpal bones; and also upon ganglionic tumors of this 
region. 

The Anterior Figure of 8 of the Hand and Wrist. Com- 
position. — The same as for the posterior figure of 8. 

Application. — The turns of the bandage are made in the same gene- 
ral manner as in the previous bandage, only the crosses are placed over 
the palm. 

Use. — To retain dressings upon the palm. 

The Figure of 8 of the Elbow. Composition. — 1st, a roller 
bandage four yards long and two inches wide; 2d, a square compress 
of patent lint or muslin. 

Application. — In applying the figure of 8 of the elbow to the right 
arm, let it be placed in a position of supination ; place the compress on 
the wounded vein, and then allowing three or four inches of the initial 
end of the bandage to hang free from the outer margin of the arm, at 
a point three inches above the compress, make a circular turn, and, 
arriving at the outer margin of the elbow, conduct the roller obliquely 
over the compress to the ulnar margin of the forearm, around the 
upper part of which one circular turn is to be made, and then passing 
from its radial border cross the compress again to the inner margin of 
the arm, and pass over its posterior surface to its outer margin — the 
point of departure. Kepeat this course once again, and terminate the 



RECURRENT BANDAGES. 199 

bandage by knotting the ends of the roller upon the outer border of 
the arm. 

Use. — To maintain a compress over a vein punctured in venesec- 
tion. After the bandage is applied the arm should be semi-flexed and 
carried in a sling until the little wound made by the lancet shall have 
cicatrized. 

The Extensor Figure of 8 of Arm and Hand. Composition. — 
A roller six yards long and two inches wide, wound in two cylinders 
or heads. 

Application. — Let the hand be pronated and strongly extended 
upon the forearm, place the body of the roller upon the posterior sur- 
face of the hand, just above the metacarpo-phalangeal articulation ; 
then conduct the two heads across the palm in opposite directions and 
bring them to the dorsum, where you cross them with a reverse, to go 
to the palm, whence they are brought again to the dorsum. Now 
passing in opposite directions, one of the heads is conducted around 
the radial margin of the hand obliquely across the forearm to the 
outer condyle, the other around its ulnar border obliquely across 
the former band to the inner condyle ; they are then crossed above 
the olecranon, to be brought circularly to the front aspect of the arm, 
crossed here, and the upper turn reversed upon the lower, when they 
are passed posteriorly, and crossed above the olecranon ; afterwards 
one roller courses along the radial border of the forearm to the ulnar 
border of the hand and to the palm, and the other turns around the 
inner border of the arm, crossing the forearm to the radial border of 
the hand and palm. In this manner two or three turns may be made, 
and the bandage exhausted by circular turns of the hand. 

Use. — To prevent vicious cicatrices of the palm after burns pro- 
ducing deformities of the hand. 

The Flexor Figure of 8 of the Hand and Arm. Composition. 
— Same as the previous bandage. 

Application. — The hand should be in a state of forced flexion, and 
the body of the bandage placed upon its palm; the rest of the bandage 
is executed in the same manner as the extensor figure of 8. 

Use. — To prevent cicatrices of the dorsum of the hand, producing 
deformity. 

§ 4. Recurrent Bandages. 

The Recurrent Bandage after Amputation of Arm and Fore- 
arm. Composition. — A roller seven yards long two inches wide, 
wound in two heads. 

Application. — This is applied in the same manner as the recurrent 
of the lower extremities after amputation. 

The Recurrent Bandage of the Shoulder (after Disarticu- 
lation). Composition. — A roller twelve yards long and two inches 
wide, wound in two unequal heads. 

Application. — Apply the proper dressings, compresses, and a Maltese 
cross over the shoulder, then place the body of the roller upon the 
axilla of the sound side, and bring the two heads obliquely across the 
chest, one in front, and the other behind, to the acromion process above 
the wound. At this point the anterior cylinder should be reversed 



200 SPECIAL, OR REGIONAL BANDAGING. 

■upon itself, and brought down vertically behind the wound, to a point 
two inches below it ; the posterior cylinder continues its original course 
across the reverse, and down obliquely from the point of the shoulder 
to the opposite side, and around the chest circularly to cross the ver- 
tical turn of the other head, which is now reflected upwards, so as to 
form a loop around the circular turn, to the acromion again. The 
cylinder coursing horizontally now passes in front of the chest, around 
the side, and obliquely over the back to the acromion, to cross the 
second vertical turn and fix it above, while the roller making the 
vertical turns descends again over the wound. Continue in this man- 
ner to make vertical turns with one of the heads of the roller, and 
horizontal and oblique turns with the other until the shoulder is en- 
tirely covered. Terminate the bandage by two or three circular turns 
around the chest. 

Use. — To retain dressings upon the shoulder after disarticulation. 

§ 5. Handkerchief Bandages. 

The Large Quadrilateral Scarf of the Arm and Chest. 
Composition. — A piece of muslin about one yard and an eighth long, 
and two feet and a quarter broad. 

Application.- — Place one of the long borders of the piece of muslin 
transversely across the chest and below the breasts; conducting its 
angles posteriorly, fasten them together over that part of the thorax 
opposite the injured side. Now raise the inferior border upwards, 
after having bent the forearm, at an angle of 45°, over the whole 
upper extremity, and carry one of its angles over the shoulder of the 
injured side, and the other under the axilla of the opposite side, and 
tie or pin them together upon the back. 

Use. — This bandage answers the purpose of supporting the whole 
arm, and retaining it in contact with the chest. It may be also ap- 
plied when the bandage of Desault is employed in the treatment of 
fracture, that the turns of the latter may be pinned to it. 

The Large Triangular Scarf of the Arm and Chest. Com- 
position. — A piece of muslin a yard and one-eighth square, folded in 
a triangle. 

Application. — Place the base of the triangle transversely across the 
chest below the mammaB, conduct its extremities posteriorly, and tie 
or pin them together upon the side opposite the affected arm. Eaise 
its apex over the arm after this has been bent to an angle of 45°, or 
any desired angle, and carry it over the shoulder of the injured side, 
to be attached to the bandage behind, using a short strip of muslin if 
it should be not sufficiently long to reach. 

Use.— This bandage will answer the same indications as the former ; 
but from the fact of its being double, is more heating and is not so 
solid. 

The Large Oblique Scarf of the Arm and Chest. Composi- 
tion. — A piece of muslin a yard and one-eighth square, folded in a 
triangle. 

Application. — Let the arm be bent at an angle of 45° and directed 
across the chest; then, taking the middle of the base of the triangle 



COMPOUND BANDAGES. 201 

in both bands, tbe surgeon glides it under tbe elbow and along the 
under surface of the forearm to the hand. Its lateral extremities are 
then conducted upwards, one in front of the arm and chest, and the 
other behind the chest, to the shoulder of the healthy side, over which 
they are to be tied. Now bring the apex of the triangle around the 
outer margin of the arm and pin it to the anterior extremity. 

Use. — To sustain the arm and forearm. 

The Scakf of the Forearm and Neck. Composition. — A trian- 
gular piece of muslin a yard and three- eighths along its base and two 
feet from base to apex. 

Application. — Flex the forearm to the desired augle, then glide the 
base of the triangle under the elbow, along the forearm to the hand, 
and conduct its extremities upwards, one between the arm and chest 
over the shoulder corresponding to the injured side, the other over 
the forearm, across the chest to the opposite shoulder ; then tie or pin 
them together over the nape of the neck. Fold the apex under the 
elbow if it should project beyond this point. 

Use. — This is the common sling used to support the forearm in 
fractures of its bones, or in inflammatory or other diseased condition 
of the hand. 

The Scarf of the Hand and Forearm. Composition. — A piece 
of muslin half a yard long and 8 or 12 inches wide. 

Application. — Place the hand and the lower part of the forearm 
upon the middle of the muslin, carry its ends upwards, and pin their 
corners to the clothes over the chest. 

Use. — To support the weight of the hand and a portion of the 
forearm, in inflammatory or other diseased condition of these parts 
requiring them to be suspended in an elevated position. 

B. Compound Bandages. 
§ 1. T Bandages. 

The Simple and Double T Bandages of the Hand. Composi- 
tion. — A roller two feet and a half long, by one inch wide : at right 
angles to this, and four inches from its initial extremity, if it is desired 
to form a single T, sew the end of a strip of muslin two feet long and 
two thirds of an inch wide; if a double T is required, the ends of two 
such strips must be tacked to the horizontal one, the first at three, 
and the second at five inches from its initial extremity. 

Application. — Give the hand a prone position, and then place the 
initial extremity of the horizontal band at that part of the wrist 
where, upon making one circular turn, the two vertical strips will 
correspond with the first and fourth inter-metacarpal spaces, one over 
each ; they should then be carried between the two corresponding 
fingers to the palm and wrist, at which latter point the circular band 
passes around them. The vertical strips are looped around it and 
reflected downwards, the first one passing between the index and 
middle fingers, the other between the middle and ring fingers, to the 
back of the hand and wrist, where they are confined by being tied 
together over a circular turn. The bandage is terminated by circular 
turns around the wrist. 



202 

The single T is applied in the same manner ; the vertical strips 
cover but two of the metacarpal spaces. 

Use. — A light retentive bandage for retaining dressings upon the 
dorsum and palm of the hand ; and is also used to prevent adjacent 
ringers uniting at their bases during cicatrization after burns. 

The Perforated T of the Hand. Camposition. — A piece of 
muslin ten to twelve inches long and three to four inches wide, per- 
forated at its middle by five holes for the fingers, and having sewed 
to one of its ends the middle of a strip of muslin a foot and a half 
long and an inch wide. 

Application. — Engage the fingers in the holes, and draw the ex- 
tremity having the strip attached over the back of the hand to the 
wrist; then, in like manner, arrange the other extremity upon the 
palm and front of the wrist, and fix them both, by circular turns of 
the strip, to this part ; finally knot its ends together. 

Use. — Answers the same indication as the preceding bandage. 

§ 2. Sling Bandages. 

The Anterior Sling Bandage of the Hand. Composition. — 
A piece of muslin sixteen inches long and three or four inches wide, 
split at each extremity, so as to leave an intervening portion of three 
inches. 

Application. — Place the body of the sling upon the palm of the 
hand, and tie its inferior extremities around the base of the fingers, 
and its superior ones around the wrist. 

Use. — To confine dressings upon the palm of the hand. 

The Anterior Sling of the Elbow. Composition. — A piece of 
muslin eighteen inches long and three or four wide, split at each 
extremity in two tails. 

Application. — Place the body of the sling upon the bend of the 
elbow, and tie its inferior ends around the upper portion of the fore- 
arm, and its superior ones around the arm. 

The posterior sling is made in the same manner; its body is 
applied over the olecranon. 

Use. — To maintain topical applications upon the front and back 
aspects of the elbow. 

§ 3. Sheath Bandages. 

The Sheath for the Finger. Composition. — A sheath of muslin 
resembling the finger of a glove, large enough to cover the finger and 
the dressings upon it, and having attached to the posterior portion of 
its base two threads, or a strip of muslin. 

Application. — Slip the sheath over the finger and tie the threads 
around the wrist to prevent its slipping off, or fix the end of the strip 
of muslin to the same part, by two threads attached to its angles. 
The finger of a glove will often answer the same purpose as the sheath. 

Use. — To maintain dressings upon the fingers. 

§ 4. Laced and Buckled Bandages. 

The Strait Jacket. Composition. — A stout piece of canvas, suf- 
ficiently wide to surround the trunk and long enough to reach from 



UPPER EXTREMITIES. 203 

the top of the shoulder to the middle of the thighs. Along its 
lateral margins a series of corresponding eyelet holes are worked, or, 
what will equally answer, a number of little loops. Upon the inner 
surface of the canvas, at each side corresponding to the shoulders, two 
long pieces of the same material are sewed, forming sheaths for the 
arms. At the extremities of the sleeves holes are cut through the 
canvas for the hands to project exteriorly, that the pulse at the wrist 
may be within reach of the physician. 

Application. — Slip the arms into the sleeves, and bring the canvas 
up snugly around the body, and, having drawn the eyeletted margins 
behind, lace them together with a stout cord. To still further restrain 
the movements of the patient, a number of loops may also be fastened 
to the top, bottom, and sides of the jacket, through which a cord 
may be passed and tied to the bedstead. A more comfortable arrange- 
ment is to place the patient's hands in leathern mittens with a strong 
loop at each wrist, through which a leathern strap passes, and buckles 
around the patient's waist. 

Use. — To restrain the violence of the insane, and of those un- 
manageable from delirium or other causes. 

The Laced Bandage of the Arm. Composition. — A piece of mus- 
lin three or four inches wide, sufficiently long to encircle the arm, and 
perforated at its extremities by four holes at equal intervals. Take 
two pair of doubled cords, one of which is passed through the two 
upper holes in such a manner that their extremities go in opposite 
directions and leave a loop upon each margin of the muslin. Arrange 
the other pair in the same way in the lower holes, and then knot the 
four extremities together upon each side, an inch from the bandage, 
and cut off all the ends but one. 

Application. — Slip the bandage over the arm, arrange it properly 
over the dressings upon that part, and draw the cords in opposite 
directions to approximate its edges, and terminate the bandage by 
two circular turns of the cords around the arm. 

Use. — To retain dressings upon the arm after blistering, applying 
the moxa, etc. 

C. Mayor's Bandages for the Upper Extremities. 

Cravats, Triangles, and Squares for the Fingers, Hand, 
Forearm, and Arm. — Cravats are in popular use, and employed daily 
for the more trifling injuries of the arms, applied either circularly 
around the parts or variously arranged, forming crossed or figure of 8 
bandages of the hand and wrist, and of the elbow. They are fre- 
quently effectual substitutes for the more complicated roller bandages. 
The same remark applies to oblong pieces of muslin, which are applied 
circularly around the limbs, and pinned at their corners. 

The Carpo-Digito-Dorsal Triangle, and the Carpo-Digito- 
Palmar Triangle. Composition. — A triangular piece of muslin 
twenty inches long, and ten inches from its base to its apex. 

Application. — Place the base of the triangle upon the anterior or 
posterior aspect of the wrist, cross its angles behind, and tie them 



204 SPECIAL, OR REGIONAL BANDAGING. 

together upon the opposite side; then conduct the apex of the triangle 
over the ends of the fingers and palm of the hand in the carpo-digito- 
dorsal triangle, and in the reverse direction in the carpo-digito-palmar 
triangle, and pin it at the wrist. 

Use. — The first form of the bandage is intended to secure forced 
flexion, and the second forced extension of the wrist and fingers. 
They may also be used as retentive means for applications upon the 
anterior and posterior aspects of the hand. 

The Interdigital Triangle. Composition. — A triangular piece 
of muslin twelve inches long and eight inches high. A short distance 
above its base pierce five holes for the fingers to pass through. 

Application, — Engage the fingers through holes, and draw the base 
of the triangle to the wrist, around which its lateral angles are tied ; 
then, in like manner, pull its apex down to the wrist upon the oppo- 
site side, and pin it. 

Use. — To prevent the union of the fingers during cicatrization after 
burns ; it may also be used as a retentive bandage for dressings upon 
the dorsum and palm of the hand. 

The Palmo-Digito-Brachial Triangle. Composition. — 1st. A 
triangular piece of muslin a yard and an eighth long from end to end, 
and seventeen inches high. 2d. A cravat, two feet and a half long. 

Application. — Fasten the cravat circularly around the arm just 
above the elbow, then place the base of the triangle upon the palmar 
surface of the wrist around which its lateral angles are tied ; conduct 
its apex over the points of the fingers placed in a position of forward 
extension, and fasten it to the cravat at the elbow. 

Use. — The bandage is employed in wounds and burns about the 
w r rist, according to the circumstances of the case, to prevent deformity 
during cicatrization. 

The Carpo-Olecranon Cravats (Fig. 132). Composition. — Two 
cravats a foot and a half long, and a third cravat a yard and a quarter 
long. 

Fig. 132. 




The carpo-olecranon cravat. 

Application. — Encircle the arm just above the elbow with one of the 
short cravats, and the hand with the other ; then forcibly extend the 
hand upon the forearm and connect the two cravats by the long one 
looped around them, and tie its extremities upon the outer aspect of 
the arm ; or the hand may be forcibly flexed before the third cravat is 
arranged. 

Use. — These two forms of carpo-olecranon cravats are employed 
as substitutes for the extensor and flexor figure of 8 bandages of the 



eigal's bandages fob the upper extremities. 2 a 

arm and hand, and. conjoined with a short splint upon the front of the 
elbow, are used in fractures of the olecranon process. 

The Carpo-Cervical Cravats. . — Two cravats: one. 

two feet long, the other, a yard. 

■ication. — Tie the short cravat loosely around the neck, then 
place the lower part of the forearm, flexed at right angles with the 
arm, upon the middle of the long cravat, and conduct its extremities 
upwards and tie them to the cervical cravat. 

Use. — To support the arm. and keep it flexed during the union of 
wounds upon the anterior aspect of the elbow, or cicatrization of burns 
about the olecranon. 

The Ceevico-Brachial Triangle. Composition. — A cravat two 
feet long, and a triangle a yard long and sixteen inches high. 

— Knot the cravat loosely around the neck with the tie 
in front, then slide the base of the triangle under the elbow along the 
under surface oi the torearm to the hand, conduct its two lateral angles 
upwards, one upon each side of the arm, and fasten them to the cervi- 
cal cravat. Bring its apex around the outer border of the arm,' and 
fasten it to the bandage in front. 

Use. — To support the forearm, and is used as a substitute for the 
scarf bandages. 

The Triangular Cap fob the Shoulder. Composition.-— A cra- 
vat two feet long, and a triangle a yard long and sixteen inches high. 
lion. — Place the body of the cravat in the axilla of the sound 
side, and tie its tails together over the opposite shoulder ; then place 
the base of the triangle below the wound upon the upper and outer 
third of the arm around which its tails or lateral angles are to be tied ; 
the apex of the triangle is then carried over the point of the shoulder, 
and fastened to the cravat. 

Use. — To retain dressings upon the shoulder. 

The Triangular Cap "for the Shoulder (after Disarticula- 
tion). Composition. — Same as in the previous bandage. 

Application. — Fasten the cravat as was done in the previous band- 
age : place the base of the triangle below the wound, then reflect its 
three angles upwards, aud fasten them to the cravat above the shoulder. 

Use. — To maintain dressings upon the shoulder after disarticulation. 

D. Eigal's Bandages for the Upper Extremities. 

The Deltoid Bandages. C i. — A square piece of muslin 

folded in a triangle, and elastic cords. 

Ay . — Place the base of the triangle upon the upper third 

of the arm, carry its lateral angles around this part and knot them 
upon its outer side: draw the apex of the triangle towards the neck. 
pulling one of its parts in front and the other behind, and tie them 
together over the sound shoulder. 

To render the bandage more firm, an elastic cord is attached to the 
margin of the triangle in front and behind, passing beneath the sound 
axilla: a second elastic cord is tied anteriorly and posteriorly. ; 



206 SPECIAL, OR REGIONAL BANDAGING. 

i 

first cord and above to the knot formed by the tails of the triangle 
upon the shoulder. 

Use. — To retain dressings upon the shoulder. 

SECTION IY. 

BANDAGES OF THE LOWER EXTREMITIES. 

SIMPLE BANDAGES. 

Circular Bandages. 

The circular bandage of a toe. 

The circular bandage of the leg. 
Spiral Bandages. 

The spiral bandage of a toe. 

The spiral bandage of the leg. 

The spiral bandage of the thigh. 

The spiral bandage of the lower extremity. 
Figure of 8 Bandages. 

The figure of 8 bandage of a toe. 

The figure of 8 bandage of the foot and leg. 

The posterior figure of 8 bandage of the knee. 

The anterior figure of 8 bandage of the knee. 

The figure of 8 bandage of both knees. 
Eecurrent Bandages. 

The recurrent bandage of the leg. 

The recurrent bandage of the thigh. 

The recurrent bandage of the hip. 
Invaginated Bandages. 

The invaginated bandage for longitudinal wounds. 

The invaginated bandage for transverse wounds. 

COMPOUND BANDAGES. 
T Bandages. 

The single T bandage of the foot. 

The double T bandage of the foot. 
Sling Bandages. 

The sling bandage of the instep. 

The sling bandage of the heel. 

The sling bandage of the knee. 
Sheath Bandages. 

The sheath bandage of a toe. 
Laced Bandages. 

The laced bandage of the lower extremity. 

MAYOR'S BANDAGES FOR THE LOWER EXTREMITY. 

Cravats, triangles, and squares of the toes, foot, leg, and thigh. 

Imbricated squares and cravats. 

The tibial triangle. 

The popliteal cravat. 

The tarso-patellar cravat. 

The compound metatarso-patellar cravat. 

The tarso-pelvic and tarso-crural cravats. 

The triangular cap for stumps. 

The triangular cap for the heel. 

The metatarso-malleolar cravat. 

The malleolar-phalangeal triangle. 

The tibio-cervical cravat. 

The uniting cord for longitudinal wounds. 

RIGAL'S BANDAGES FOR THE LOWER EXTREMITY. 

The triangle of the trochanter major. 
The bandage for the leg. 
The bandage for the foot. 



SIMPLE BANDAGES. 207 

A. Simple Bandages. 
§ 1. Circular Bandages. 

The Circular Bandage of a Toe. — The composition and appli- 
cation of this bandage are the same as that of the circular bandage of 
a finger already described. 

The Circular Bandage of the Leg for Venesection. Com- 
position. — A slip of muslin a yard long and three inches wide, folded 
in the direction of its length. 

Application. — Place the body of the banclelette upon the leg two or 
three inches above the malleoli, conduct its extremities around the 
limb, cross them upon its opposite side, and finally regain the place of 
departure, when they are to be tied in a single bow-knot either upon 
the inner or the outer side of the leg, according as the vein to be punc- 
tured is upon the outer or inner surface of the foot ; the knot being 
always opposite to it, that the ends may not be soiled nor interfere 
with the flow of blood. 

Use. — This bandage is used exclusively in venesection in the foot, 
serving to arrest the return of venous blood. It will be necessary to 
draw it pretty tight ; and the foot may be previously immersed for 
half an hour in hot water to facilitate the congestion of the veins. 

§ 2. Spiral Bandages. 

The Spiral Bandage of the Toe. — The composition and appli- 
cation of this bandage are the same as those of a spiral of a finger 
already described. 

The Spiral of all the Toes. — The composition and application 
of this bandage are also the same as those of the gauntlet or spiral of 
all the fingers. 

The Spiral of the Foot. Composition. — A roller four yards long 
and two inches wide. 

Application. — If the right foot is to be bandaged, let the patient be 
seated in front of the surgeon with the heel upon his knee ; then make 
two circular turns around the ankle to confine the initial extremity ; 
when the roller arrives at the external malleolus, conduct it across 
the dorsum of the foot to the root of the big toe ; here change its di- 
rection, and make circular and reverse turns around the forepart of 
the foot to near the middle of its outer border ; now pass from this 
point up over the instep, down its inner side, and across the apex of 
the heel to its outer side, then across the instep, again, and around 
under the heel, covering in the lower third of the previous turns ; in 
like manner make a third turn around the heel, which should cover 
in the upper third of the first one ; and at the termination of this, 
when the roller comes to the top of the foot, carry it around its inner 
border under the sole, around the outer malleolus and the tendo- 
Achilles, and obliquely upon the inner surface of the os calcis across 
the sole of the foot to its outer border. From this point the cylinder 
comes obliquely across the instep around the tendo- Achilles and over 
the outer surface of the os calcis, under the foot to its inner margin 



208 SPECIAL, OR REGIONAL BANDAGING. 

and up over the instep, and round the lower portion of the leg, when 
the bandage is terminated by two or three circular turns. In this 
manner the heel is perfectly and neatly covered in, and the entire sur- 
face of the foot from the root of the toes to the leg compressed in a 
uniform manner. 

Use. — This bandage is employed almost exclusively for the purpose 
of making compression upon the foot; when the object is simply to 
retain dressings upon the part, the covering of the point of the heel 
may not be so much regarded. In the French spiral, the heel is left 
exposed, and is very apt to swell, and become painful from the in- 
equality of the pressure. 

The Spiral of the Leg. Composition. — A roller seven yards long 
and two inches wide. 

Application. — Place the patient in the same position as directed 
above, and confine the initial extremity about the lower part of the 
leg by two circular turns, and then ascend to the knee by circular 
and reverse turns, and terminate the bandage below it by two circular 
turns. When, however, uniform pressure is desired, the foot should 
be included. In the ordinary spiral the initial extremity is confined 
around the ankle — we will say the right — and the roller conducted 
from the outer malleolus across the dorsum of the foot to the root of 
the big toe, then ascend the foot by circular and reverse turns to the 
anterior part of the heel, when the roller courses over the instep and 
around the lower portion of the leg which is covered in to the knee by 
circular and reverse turns. What has been called the French spiral 
differs from the preceding in that its initial extremity is confined 
around the forepart of the foot by circular turns; its succeeding por- 
tion is executed in exactly the same manner. 

Use. — To confine dressings upon the leg, and to make uniform 
pressure, as in chronic ulcers of that part, or in diffuse phlegmonous 
inflammation. 

The Spiral of the Thigh. Composition. — A roller seven yards 
long and two inches wide. 

Application. — Place the initial extremity of the roller upon the 
lower part of the thigh, and confine it there by two or three circular 
turns ; then ascend towards the hip by circular and reverse turns, and 
terminate the bandage by one or two turns around the pelvis. 

Use. — As a retentive for blisters, poultices, etc., applied to the thigh. 

The Spiral of the Lower Extremities (Fig. 133). Composition. — 
Two rollers, each eight yards long and two inches wide. 

Application. — If it is the right leg, for instance, to which we desire 
to apply the spiral, proceed exactly in the same manner as we have 
directed for the spirals of the foot and leg ; and in order to cover in 
the knee, when the spiral of the leg is being finished and the roller 
arrives at the outer surface of the leg, instead of conducting it circu- 
larly around this part, let it have an oblique direction upwards and 
inwards over the tubercle of the tibia to its inner side, across the 
posterior aspect of the joint, and around again in front, crossing the 
previous turn. Execute this movement two or three times, or until 
the oblique turn, passing from without inwards, is on a level with the 



FIGURE OF 8 BANDAGES. 



209 



patella ; when the roller should be carried across the upper part of 

the popliteal space, and around the thigh, above the patella, to the 

inner condyle of the femur. From this point 

the roller crosses the popliteal space again Fig. 133. 

obliquely upwards and outwards, to pass 

around the thigh in front to the point of 

departure, when in crossing the above-named 

space a third time the roller, passing obliquely 

downwards and outwards, winds around the 

outer tuberosity of the tibia, and crosses the 

previous turn obliquely to the point above 

the inner condyle of the femur, thus forming 

a figure of 8 of the knee. Descending, make 

three or four of these figures of 8 turns until 

the knee is entirely inclosed ; then make one 

circular turn around the joint over the patella, 

and gain the thigh which is to be covered in 

by circular and reverse turns to the hip. 

Use. — This beautiful bandage is employed 
to make a uniform pressure upon the whole 
extent of the inferior extremity in oedema, 
ulcers, varicose veins, inflammation, and en- 
gorgements of that part ; to arrest hemor- 
rhage, and to check the flow of blood in aneu- 
rism, and lastly, it is used by some surgeons 
in fractures of the thigh and leg. 

The most attentive care is necessary, during 
the application of this bandage, that no unne- 
cessary degree of pressure be exerted, or gan- 
grene may be the consequence. Due allow- 
ance should also be made for the subsequent 
swelling of the injured limb. 

§ 3. Figure of 8 Bandages. 

The Figure of 8 of a Toe. — The com- 
position and application of this bandage are 
similar to those of the flgnre of 8 of the 
thumb already described. It should be ob- 
served, however, that the initial extremity 
of the roller should be confined around the 
anterior part of the foot, as in the former case 
it is secured around the wrist. 

Use. — To retain dressings, and make com- 
pression upon the toe. 

The Figure of 8 of the Foot axd Leg. 
six yards long and two inches wide. 

Application. — Confine the initial extremity two inches above the 

malleoli by two or three circular turns ; and when the roller arrives 

at the inner aspect of the ankle, conduct it across the dorsum of the 

foot to the fifth tarso- metatarsal articulation : then pass beneath the sole 

14 



The spiral bandage of the lower 
extremity. 

Composition. — A roller 



210 

transversely to its inner margin, and make one circular turn around 
the metatarsus, when the roller should be carried obliquely across the 
instep to the outer malleolus, and around the posterior surface of the 
leg to the inner malleolus, thus completing the figure of 8. Go over 
the same course a second time, and complete the bandage by circular 
turns around the ankle. 

Use. — This bandage may be used to retain dressings upon the ankle, 
instep, and sole of the foot ; but it is generally restricted to making 
compression upon the internal saphenous vein after venesection at this 
point. 

The Posterior Figure of 8 of the Knee (Fig. 134). Composi- 
tion. — A roller six yards long and two inches wide. 

Application. — Confine the initial extremity of the roller three inches 
above the patella by two or three circular turns around the thigh. 

Arriving at the external con- 
Fi s- 134 - dyle, conduct the roller ob- 

liquely across the popliteal 
space to the inner border of 
the tibia, and around the 
anterior surface below its 
tubercle to the head of the 
fibula; from this point make 
one circular turn of the up- 
per portion of the leg, when 
The posterior figure of 8 of the knee. the roller should be again 

carried obliquely across the 
popliteal space to the inner condyle, crossing the previous turn ; then 
around in front of the thigh to the outer condyle, thus completing 
the figure of 8. Eepeat the same manoeuvre again, and complete the 
bandage by circular turns about the lower portion of the thigh. 

Use. — To maintain topical applications as poultices, etc. upon the 
popliteal space, and to make compression upon the popliteal artery, 
an appropriate compress having been previously placed over that 
vessel. 

The Anterior Figure of 8 of the Knee. — The composition and 
application of this bandage are similar to those of the posterior figure 
of 8, only the crosses are to be made over the patella instead of the 
popliteal space. 

Use. — To retain dressings upon the anterior aspect of the knee. 
The Figure of 8 of Both Knees. Composition. — A roller six 
yards long and two inches wide. 

Application. — Having confined the initial extremity of the roller to 
the lower part of one of the thighs by circular turns, place the two 
knees in contact, with a compress between them to prevent their mutual 
pressure causing excoriation, and then proceed exactly in the same 
manner as directed for the execution of the figure of 8 of one knee. 

Use. — To retain the limbs motionless in fracture of the neck of the 
femur and after the reduction of dislocation at the hip, and also to 
approximate the thigh in the healing of a ruptured perineum. 




RECURRENT AND INVAGINATED BANDAGES. 211 

§ 4. Recurrent Bandages. 

The Recurrent Bandage after Amputation. — The composition 
and application of the recurrent bandages of the arm and forearm are 
identical with those of the leg and the thigh now to be described, only 
the number of reverses are less numerous in consequence of their 
smaller size. 

The Recurrent for the Thigh (after amputation). Composition. 
— A roller twelve yards long and two inches wide. 

Application. — Apply the desired dressings upon the end of the 
stump, and cover them with a Maltese cross ; then confine the initial 
extremity of the roller six or eight inches above the flaps by three or 
four circular turns; coming to the outer side of the left thigh, for 
example, reverse the roller and carry it perpendicularly over the end 
of the stump to its inner side, where another reverse is made to give 
it a circular direction around the thigh, passing from within outwards, 
and making two circular turns to confine the reverse. When the roller 
arrives at the middle of the anterior surface of the thigh, reverse it to 
make a vertical turn over the centre of the flaps, and, coming to a 
corresponding point upon its posterior surface, reverse again, and 
make two circular turns ; then cover in by vertical turns, first one 
side, and then the other of the stump, securing the two reverses of 
each turn by two circulars. 

This recurrent can also be effected with the double-headed roller 
by placing its body upon some point of the circumference of the limb 
six or eight inches above the wound ; conduct the cylinders around 
the limb to the opposite side, where they should be crossed ; make 
two circular turns in this manner, and then give one of the heads a 
vertical direction to make the recurrent turns, which are held by cir- 
cular turns made with the other head. 

Use. — This bandage is employed to retain dressings upon the stump 
of an amputated limb; that made with the single-headed is more 
simple but less firm than that executed with the double-headed roller. 

The Recurrent of the Hip (after disarticulation). Composition. — 
A roller twelve yards long and two inches wide. 

Application. — Confine the initial extremity of the roller around the 
loins by two or three circular turns ; then, arriving at the outer sur- 
face of the hip, if it is the right side, make a reverse, and conduct the 
roller vertically across the wound over the pubis and around the left 
side to the middle of the right groin, where a reverse is made and a 
vertical turn carried over the centre of the flaps to the posterior sur- 
face of the pelvis ; here another reverse becomes necessary, to enable 
the roller to make two circular turns. Now proceed to cover in, first 
one side and then the other of the wound, by circular and vertical turns, 
and finish the bandage by two or three circular turns around the waist. 
Use. — To confine dressings upon the hip after disarticulation. 

§ 5. Invaginated Bandages. 

The Uniting Bandage for Vertical Wounds (Figs. 135, 136). 
Composition. — 1st. A piece of muslin as wide as the length of the 



212 



SPECIAL, OR REGIONAL BANDAGING. 



wound, and long enough to encircle the limb five or six times ; split 
one of its ends into three or more heads, twelve to sixteen inches long, 



Fig. 135. 



Fig. 136. 




Invaginated bandage for vertical wounds. 

and at a distance from their base equal to the circumference of the 
limb, perforate the cloth with a corresponding number of slits. 2d. 
Two prismatically graduated compresses, somewhat longer than the 
wound itself, and of a thickness proportional to its depth. 

Application. — Place the injured extremity in such a position that 
the most perfect relaxation of the wounded parts may be obtained ; 
and to prevent engorgement of its lower portion, encircle it with 
a roller to a level with the injury. Now apply the compresses, one 
upon each side of the incision, and. from one to two inches from 
it ; having placed the body of the bandelette upon a part of the limb 
exactly opposite to the wound, bring its extremities over the com- 
presses, draw them in opposite directions until the bandage is suffici- 
ently tightened, and terminate with circular turns. 

Use. — This uniting bandage was formerly much employed in the 
treatment of vertical wounds, but the more effectual method with 
adhesive strips has almost supplanted it. Its use is also restricted 
from the rarity of wounds exactly vertical. 

The Spiral Invaginated Bandage for Vertical Wounds. 
Composition. — 1st. Two graduated compresses. 2d. A band of vari- 
able length, proportionate to the volume of the parts, and four fingers 
wide, wound in two heads. 

Application. — To apply the bandage upon a limb, commence by 
covering it with a spiral from the fingers or toes up to the wound ; 
afterwards apply that portion of the band intermediate to the two 
cylinders upon that point of the body or of the limb which is oppo- 
site to the wound ; conduct the two cylinders horizontally over the 
inferior extremity of the wound, upon each side of which a gradu- 
ated compress is held by an assistant ; make in the band of one of the 
cylinders a slit that corresponds to the wound, and sufficiently large 
that the opposite cylinder can pass through it easily; pass the cylin- 
der through this slit in such a manner that the crossing of the bands 
which results rests over graduated compresses ; direct afterwards the 
two cylinders to the point of departure, ascending a little, and making 
a circular turn which covers two-thirds of the first one; having 




COMPOUND BANDAGES. 213 

arrived at the point opposite to the wound where you commenced 
the bandage, simply cross the cylinders, reversing one upon the other; 
return over the wound, ascending still more, then perforate again the 
band of one of the cylinders in the same manner, and invaginate them 
as before; repeat this process until the wound is covered, and termi- 
nate the bandage by oblique turns of the neck and axilla, if it is applied 
upon the arm, and by circulars around the pelvis if to the thigh. 

Use. — This bandage was used by M. Gerdy as a substitute for the 
preceding, believing it to possess more advantages and to be decidedly 
firmer for a wound eight or ten inches in length. 

The Invaginated Bandage for Transverse Wounds (Fig. 137). 
Composition. — 1st. A roller ten yards long and two inches wide. 2d. 
Two strips of muslin two feet long and of a width corresponding to 
the breadth of the limb. Split 

the end of one of these strips Fi S- 137 * 

into three or four heads a foot 
long, and perforate the middle of 
the other with a corresponding 
number of slits. 3d. Two pris- 
matically graduated compresses. 

Application. — Place the limb 
in a position most favorable for 
relaxing the muscles of the 

parts, and then lay Upon itS an- Invaginated bandage for transverse wounds. 

terior aspect the two bandelettes 

with their heads and fenestras regarding each other ; then commencing 
below, secure these by circular and reverse turns ascending towards 
the trunk. Now arrange the compresses and draw the bandelettes 
over them in opposite directions, having previously slipped the heads 
of the one through the slits of the other, when they should be secured 
by descending spiral turns. 

Use. — This bandage has been employed in fracture of the patella, 
rupture of the tendo- Achilles, and in transverse wounds of the ex- 
tremities ; but it is now rarely used. 

B. Compound Bandages. 
§ 1. T Bandages. 

The Single and Double T of the Foot. These bandages are 
prepared and applied in the same manner as the corresponding ones 
of the hand already described. 

Use. — To confine dressings upon the upper and lower aspect of the 
foot, and also to prevent the union of the toes during cicatrization. 

§ 2. Sling Bandages. 

The Sling op the Instep. Composition. — A piece of muslin a 
foot and a half long and three inches and a half wide, split at each 
end in two tails. 

Application. — Place the body of the bandage upon the instep, tie 



2U 



SPECIAL, OK REGIONAL BANDAGING. 



the inferior tails around the foot and the superior ones around the 
lower portion of the leg. 

Use. — To maintain topical dressings upon the foot. 

The Sling of the Heel. Composition. — The same as the pre- 
ceding. 

Application. — Place the body of the sling upon the heel, fasten the 
inferior tails around the forepart of the foot, and the superior ones 
around the inferior portion of the leg. 

Use. — This is a very simple retentive bandage for holding charpie 
or other dressings to the heel. 

The Sling of the Knee (Fig. 138). Composition. — A piece of 

Fig. 138. 




The sling of the knee. 

muslin a yard long and a quarter wide, split at each extremity in two 
tails. 

Application. — Lay the body of the sling over the patella, or popliteal 
space, tie the superior extremities around the inferior part of the thigh, 
and the inferior ones around the superior portion of the leg. 

Use. — To maintain dressings upon the knee. 



Fig. 139. 




Laced bandage. 



§ 3. Sheath Bandages. 

The Sheath Bandage for the Toe. — This 
bandage is prepared and applied in the same 
manner as the sheath for the finger. 

Use. — This is a convenient manner of retaining 
dressings upon the toes. 

§ 4. Laced Bandages. 

The Laced and Elastic Bandages of the 
Foot and Leg (Fig. 139). — These bandages 
were formerly most frequently made of cotton or 
woollen cloth, kid, buckskin, or silk, with eyelet 
holes in their lateral margins, through which a 
long lacing cord passed, and by means of which 
they could be closely applied to the limb. At 
present India-rubber in some of its forms is 
much more commonly employed in their manu- 
facture, and the use of the cord done away with. 
The bandage seen in Fig. 139 is thus prepared ; 
the letters indicate the position of the lines of 
measurement for making the bandage by. 



mayor's bandages. 215 

Use. — To make uniform compression of the lower extremities in 
varicose dilatation of the veins, sprains of the ankle and knee, in 
cases of loose cartilages in the latter joint, and when the patella is 
readily disposed to luxation. 

C. Mayor's Bandages for the Lower Extremities. 

The Cravat, Triangle, Square Muslin and Handkerchief 
may often be advantageously had recourse to in various injuries of 
the thigh, leg, foot, and toes ; their application is simple, and needs no 
special notice here. 

Imbricated Squares and Cravats. — These are recommended by 
Mayor as substitutes for the spiral bandage of the lower extremity, 
and the bandage of Scultetus. Their composition and application are 
obvious. 

The Tibial Triangle. Composition. — A triangular piece of mus- 
lin a yard long and sixteen inches from the base to its apex. 

Application. — Place the middle of the base crosswise beneath the 
patella, conduct one of the lateral angles around the calf of the leg, 
and pin it at the upper part of the bandage ; the other angle should 
be carried in the opposite direction aroand the calf, and fastened over 
the lower aspect of the leg. The apex is now to be drawn around the 
calf, and pinned to the centre of the triangle over the tibia. 

Use. — This bandage may be conveniently used for retaining dress 
ings upon the leg, such as blisters and poultices, &o. 

The Popliteal Cravat. Composition. — A cravat a yard long. 
- Application. — Place the middle of the cravat above the popliteal 
space, conduct the two ends forward, cross them over the patella and 
again over the popliteal space, and finally draw them forwards and 
tie or pin them together over the tibia. 

Use. — Employed in those cases in which the posterior figure of 8 
of the knee is indicated. 

The Tarso-Patellar Cravats. Composition. — Three cravats, each 
a yard long. 

Application. — Tie one of the cravats loosely around the tarsus, place 
the base of another one upon the front of the thigh above the patella, 
cross its extremities over the popliteal space and fasten them together 
below the knee in front. The middle of the third cravat should loop 
around the tarsal cravat, and its extremities be carried up under the 
upper cravat, one upon each side, and then reflected upon themselves 
and pinned. 

Use. — This bandage is used in fractures of the patella, and in trans- 
verse wounds of the anterior surface of the ankle. 

The Compound Metatarso-Patellar Cravats. Composition. — 
1st. Five cravats, each a yard long. 2d. A paste-board gutter splint. 

Application. — Arrange three of the cravats in the same manner as 
directed in the tarso-patellar cravats, and raise the limb somewhat 
above the plane of the back, by placing a pillow under it ; let the gutter 
splint be now applied beneath the knee and fastened with the remain- 
ing cravats to the limb, one encircling the leg and the other the thigh. 



216 SPECIAL, OR REGIONAL BANDAGING. 

Use. — In fractures of the patella. It is much more firm and efficient 
than the preceding bandage, and should always take the precedence 
of it in the treatment of this fracture. 

The Tarso-pelvic and Tarso-crural Cravats. Composition. — 
Three cravats each a yard long. 

Application. — Fasten one of the cravats around the tarsus, a second 
around the pelvis; then bend the leg upon the thigh and forcibly 
extend the foot upon the leg ; and loop the middle of the third cravat 
around the lower one, over the sole of the foot : carry its extremities 
upwards under the pelvic cravat and knot them together. The other 
cravat may be fastened around the upper part of the thigh (tarso- 
crural) ; but this modification is less advantageous or efficient than 
the tarso-pelvic cravats. 

Use. — To flex the leg in transverse wounds of the posterior aspect 
and popliteal space, and to extend the foot in rupture of the tendo- 
Achilles. 

The Triangular Cap for Stumps. Composition. — A triangle one 
yard long and sixteen inches from base to apex. 

Application. — Place the base of the triangle upon the anterior sur- 
face of the stump, conduct its extremities posteriorly, cross them 
behind, and bring them forwards and kuot together in front ; reflect 
the apex over the wound, and pin it over the centre of the bandage. 

Use. — With this triangle a stump of any limb may be conveniently 
and quickly dressed. The cap may be prevented from slipping off 
by sewing two strips to its base and fastening them around the joint 
above, or in the case of the thigh and arm around the pelvis and neck. 

The Triangular Cap for the Heel. Composition. — A triangle 
a foot and a half long and ten inches high. 

Application. — Place the base of the triangle under the heel, conduct 
its lateral angles around the instep and the lower portion of the 
leg, and tie them together over the tendo- Achilles ; turn the apex 
upwards over the heel and fasten it to the bandage behind. 

Use. — Employed as a retentive bandage for the heel. 

The Metatarso-Malleolar Cravat. Composition. — A cravat 
two feet long. 

Application. — Place the middle of the cravat obliquely across the 
instep, carry the higher extremity around the ankle, and lower one 
under the sole of the foot to the dorsum, where the ends should be 
tied together. 

Use. — A simple retentive bandage for dressings tied over the in- 
step. 

The Malleolar Phalangeal Trt angle. Composition. — A tri- 
angle a couple of feet long and a foot deep. 

Application. — Place the middle of the base of the triangle under the 
instep, reflect its apex over the toes to the dorsum of the foot, then 
conduct the lateral angles up over the instep, cross them to go behind 
the lower portion of the leg upon each side, and cross them there ; 
finally bring them forwards and pin them together over the top of 
the foot. 



FOR THE LOWER EXTREMITIES. 2L7 

Use. — This triangle incloses the whole foot, and will serve an excel- 
lent purpose for retaining dressings upon any part of it. 

The Tibio-Cervical Cravats. Composition. — 1st. A cravat two 
yards long. 2d. A triangle a yard long and two feet deep. 

Application. — Apply the base of the cravat upon the shoulder of the 
sound side, conduct its extremities obliquely across the chest and tie 
them together upon the opposite hip ; then bend the leg at right 
angles, and glide the base of the triangle under the knee as far as the 
lower portion of the leg, where the lateral angles are carried upwards 
and fastened to the cravat ; the apex is folded round the lower and 
front face of the thigh and pinned upon the outer side of the leg. 

Use. — To support the leg after fractures or sprains, when either the 
patient desires, or the surgeon deems it necessary for him to move 
about upon a crutch, an important advantage in forwarding the con- 
valescence of a patient in bad health affected with a fracture. 

The Uniting Cords for Longitudinal Wounds. — Mayor, in 
longitudinal wounds of the extremities, employs an arrangement simi- 
lar to his uniting bandage for harelip : it requires no special descrip- 
tion in this place. In transverse wounds, he depends upon position 
simply for the approximation of their edges. 

D. Rigal's Bandages for the Lower Extremities. 

The Triangle for the Trochanter Major. Composition. — A 
square piece of muslin folded in a triangle. 

Application. — Place the base of the triangle over the right or the left 
hip, conduct its extremities around the body, and tie them upon the 
opposite side; then draw the apex downwards, separate its two angles, 
and carry them around the thigh, one in front, the other behind, to be 
fastened together upon its inner aspect. 

Use. — The same as Mayor's cap for the hip. 

The Bandage of the Leg. Composition. — A square piece of mus- 
lin folded in a triangle. 

Application. — Place the base of the triangle upon the leg below the 
knee, conduct its extremities around it and tie them together ; then 
draw down its apex around the leg, separate its two angles and tie 
them around the ankle. 

The Bandage for the Foot. — This bandage is applied in the 
same manner as the cap for the foot. 



PART II. 

MECHANICAL BANDAGES AND APPARATUS. 

We have now considered trie more simple and frequently employed 
bandages in surgical practice, and, to continue this sketch of what may 
be called the mechanics of surgery, we shall devote a few pages to 
those more complicated mechanisms had recourse to in the treatment 
of the various forms of deformities and deficiencies to which the human 
body is liable at all times, and generally designated as mechanical or 
orthopaedic bandages or apparatus. Although they have not had that 
amount of careful study and attention given them by the profession 
which their real importance would seem rigorously to demand, yet it 
must not be supposed on that account that they are of little value. 
On the contrary, if one reflects upon the subject for a moment, and 
learns that there are thousands of cases of various kinds of deformities 
in our country, particularly in our large cities, which are remediable 
in their earlier stages by the use of properly constructed mechanical 
appliances alone, and even when further advanced, can be much bene- 
fited by them ; or, again, that there is yet another and large class of 
such affections in which, after an appropriate and timely use of the 
knife in dividing tendons and ligamentous bands, the subsequent 
application of mechanical contrivances will materially hasten a speedy 
and successful issue ; he can then form some estimate both of their 
importance and the range of their application. 

In all cases of deformities, however, we should be fully admonished 
that it is in their earlier stages — in childhood, indeed — when important 
and permanent success can be secured ; and hence, how important a 
duty it is for the medical practitioner to familiarize himself with the 
subject of orthopraxy, to recognize the earliest manifestations of an 
impending deformity, so that he may be able, when the opportunity 
presents itself, to rescue a patient from the deplorable fate of a wretched 
cripple or from an unseemly deformity. 



LOSS OF PARTS OF THE HEAD AND NECK. 219 



CHAPTER I . 

APPARATUS FOR REMEDYING THE LOSS OF PARTS. 

SECTION I. 

LOSS OF PARTS OF THE HEAD AND NECK. 

Deficiency of the Cranial Walls. — From injury or operations 
performed upon the skull,, more or less of its bony walls may have 
been destroyed. In the first instance the loss may amount to several 
square inches, as is observed sometimes in sabre and gunshot wounds, 
where the brain and its membrane, being exposed, may be seen to rise 
and fall with every pulsation of the heart. In the operation of tre- 
phining, generally a small perforation of the bone only is made, and 
scarcely requires any surgical interference. 

The natural mode of cure, in such cases, is the effusion of plastic 
matter into the excavation, and its organization in a tough, strong, and 
fibrous membrane or fibro-cartilao-e, which, stretching from the edo-es 
of the bone all around, closes the opening and defends the brain from 
exterior violence. This membrane becomes sometimes ossified, and 
establishes a more effectual barrier against exterior hurtful influences. 

In those cases where the efforts of nature do not succeed to a 
sufficient extent to protect the parts beneath, either from some defect 
in the recuperative powers or from the extent of the injury, some 
mechanical contrivance becomes necessary. An extremely simple one 
consists of a metallic or gutta-percha plate, of sufficient size to cover 
the opening and rest upon its margins, and of either a flat or a slightly 
concavo-convex shape, according to the circumstances of the case, 
and painted in imitation of the scalp. 

There are three modes of retaining it in its proper situation. 1st. 
By strings affixed to its margins and colored to match the hair, and 
tied under the chin. 2d. The plate may have its edges perforated 
with numerous holes, by means of which it can be sewed to the mar- 
gins of a hole of corresponding size, cut in a skull cap of muslin or 
other material, and placed in such a manner that when the cap is upon 
the head the plate will fit exactly over the injury. 3d. The last and 
most elegant plan is to solder two slender springs to the plate, which, 
spanning the vault of the cranium, pass, concealed under the hair, 
to points situated above the ears, where they are provided with two 
little pads. Should the defect be upon one side, one spring will often 
support the plate sufficiently firm by taking its point d'appui above 
the ear of the opposite side. 

As already stated, this plate is intended to protect the brain after 
the loss of parts of its natural bony defensive walls. 

Deficiency of the Integuments. — It is occasionally necessary to 



220 APPAEATUS FOR REMEDYING THE LOSS OF PARTS. 

deprive a part of its integuments for a longer or shorter time, as 
occurs in establishing issues by the actual or potential cautery. 

The back of the neck is often selected as the point at' which the 
derivation is established in diseases of the braiu. An open issue, 
intended to be maintained for a long time, having been made, in order to 
shield it from the irritating contact of exterior agents, as the stiff hair 
upon the back of the head, and the clothes, a metallic or gutta-percha 
plate should be prepared as in the former instance, slightly concavo- 
convex, and either fastened to the neck by two» strings tying in front, 
or set in the middle of a common cravat, when the issue will be en- 
tirely concealed. 

A similar plate may be prepared for any other portion of the body. 

Deficiency of the Nose. — The nose may be partially or entirely 
destroyed by injury or disease; and plastic surgery has accomplished 
remarkable results in restoring the lost parts by the various processes 
of rhinoplasty ; yet there are numerous cases where it completely fails, 
or the patient is unwilling to undergo any operation ; and these are 
the cases for which mechanical surgery can do much in providing an 
artificial substitute. 

The nasal organ should be completely healed before any mechanical 
contrivance is placed upon it intended to correct the deformity, to 
restore timbre to the voice, and to protect the nares from irritating 
particles floating in the air which may produce chronic inflammation 
and even ulcerations of its lining membrane. 

Artificial noses were formerly constructed of linden or willow wood, 
metallic plates, and papier mache, but the lightness, indestructibility, 
and plasticity of gutta-percha commend it highly for this purpose. 

The artificial nose should be made of comely shape, in fair propor- 
tion with the symmetry of the countenance, and artistically colored. 

To maintain it in place, affix to its posterior edges two or three 
little springs, which may catch upon the inner surface of the nasal 
fissure, or solder a long spring to the apex of the artificial nose, 
ascending between the eyes and spanning the cranium, to terminate at 
the occiput, where it takes its point d'ajppui by means of a little pad. 
Should the patient wear glasses, the top of the nose may be attached 
to the bow arching across from eye to eye. 

Sometimes a small portion only of this organ is destroyed, in which 
case the substituted member should exactly resemble it, and may be 
held in place by narrow strips of adhesive or isinglass plaster stretch- 
ing over the cheek and side of the nose. This of course would be a 
very troublesome plan, and it was to remedy this that Mr. S. Snell 
invented the nose sketched below (Medico- Chirurgical Review, vol. iii., 
1825), and successfully applied it in the case of an army officer who 
had lost the greater part of his nose (Fig. 140). He thus describes the 
method of making it : "A correct model was first taken of the defec- 
tive parts, which was cast in brass, and upon which a thin gold plate 
was accurately fitted, in the manner generally adopted by jewellers. 
To the inner surface of this plate, at that part which was to form the 
septum, were soldered three pieces of gold wire, which terminated, each, 
by a small flat plate, perforated with holes, for the purpose of sewing 



LOSS OF PARTS OF THE HEAD AXD XECK. 



221 



to its outer surface a covering of India-rubber. These gold wires 



were rendered highly elastic (Fig. 141). 
Fig. 140. 



Fig. 141. 




The artificial nose. 



The appearance of the face before the artificial 
nose was attached. 

" Upon the outer side of the principal plate was next fitted a piece 
of ivory, so as entirely to cover it; the extreme edges of the ivory being 
intended to come in close contact with the face. The ivory was then 
carved to the exact shape and fashion of such a nose as appeared most 
likely to be suitable for the size and contour of the face for which it 
was intended — the under part be- 
ing hollowed out to form the nos- Fig. 142. 
trils, rendering it very light and 
thin. The gold and bone were 
now riveted to each other firmly 
by small gold pins. The artificial 
nose was then placed upon the 
face, and an artist colored it in oil, 
so as to resemble the surrounding 
parts, both in color and character. 

The nose was held in its posi- 
tion upon the face by three elastic 
wires (Fig. 142); the two lower 
ones, having a tendency to press 
outwards during confinement, 
pressed against the lateral walls 
of the nasal cavity. The upper 
spring having a similar tendency, 
pressed against the upper roof of 
the same cavity. The India-rubber 
was used for the purpose of defending the parts from the effects of 
pressure of the springs." 




The appearance of the face with the nose attached. 




222 APPARATUS FOR REMEDYING THE LOSS OF PARTS. 

Gutta-percha may be modelled in the same manner, and will afford 
a lighter and cheaper nose. 

Deficiency of the Bye.— When from injury or disease the 
front of the globe of the eye is destroyed or its contents evacuated, it 
is very desirable to remedy the deformity which is thereby caused ; 
for this purpose an elegant prosthetic substitute is made use of, called 
the artificial eye (Fig. 143). The art of manufacturing it was prac- 
tised at an early period, and two kinds were employed made of steel 
plates. The first covered the whole eye, and had eyelids, irides, &c, 
painted upon its outer surface, and was held in place by steel springs ; 
the second resembled the eye now in common use. 

Porcelain and glass are the materials of which the artist avails himself 
Fie 143 at P resent f° r making artificial eyes ; they are sec- 

tions of spheres of different diameters for adaptation 
to orbits of varying size in different persons. Each 
case requiring some special shape, according to the 
extent of injury or loss of the orbital contents. 

Considerable taste may be displayed in the se- 
lection of an appropriate eye, as to the color of the 
Artificial eye. — ^ an( j ^ Q convex ity f th e cornea, to correspond 

with the remaining organ. The selection should be made from a 
large number, and judgment as to perfect adaptability in all respects 
above mentioned should be given by a person of experience and taste. 
Another still more important point, as regards the comfort of the 
patient, is to obtain an article with perfectly smooth edges, as a very 
slight degree of roughness may cause irritation, or even inflammation 
of the parts. 

Should the remnant of the globe have the insertions of the orbital 
muscles still intact, the artificial eye fitted to its anterior surface will 
participate to some extent in its motions, and so closely resemble the 
healthy organ as to render detection of the substitute very difficult, if 
not impossible. On the other hand, when the contents of the orbit are 
wholly evacuated the eye will not possess any motion, and its vacant 
and fixed stare and want of life-like brilliancy, as compared with the 
natural organ, will often give the countenance a disagreeable expres- 
sion. The introduction of the eye should not be attempted until cica- 
trization is completed and all tenderness of the parts gone ; its inser- 
tion may then be effected by taking hold of the outer angle of the 
eye with the thumb and index finger of the right hand, after dipping 
it in water, or a thin solution of mucilage, and placing its upper edge 
gently under the superior lid, which has been raised previously by the 
index finger of the left hand, and permitted to close upon the outer 
surface of the eye ; the lower lid is now to be depressed to receive its 
inferior border. The pressure of the two lids will effectually retain 
the eye in its proper site. 

The eye, at first, should be worn only three or four hours at a time, 
until the parts become accustomed to its presence. At night it should 
be removed and kept in a glass of fresh water, which will prevent 
mucosity concreting upon its surface. 

The plan of removing the eye when necessary is very simple. The 



LOSS OF PARTS OF THE HEAD AND NECK. 223 

lower lid is depressed, and the head of a pin is inserted beneath its 
edge and the eye drawn forwards. 

In some cases, with the very best and appropriate eye, so much 
irritation is caused that the patient has to abandon its use permanently. 

Deficiency of the Ear. — For the replacement of a lost or muti- 
lated ear, a substitute may be prepared either of gutta-percha or of 
gold. 

In the first case, a cast of plaster of Paris should be made of the 
sound ear, and from this a metallic matrix or mould is prepared, into 
which the melted India-rubber is poured ; and when hardened, is vul- 
canized and then painted to imitate the natural organ. Should it be 
decided to have a gold ear, two models are made, one of the anterior 
surface of the ear, and the other of its posterior surface. Then fit two 
thin gold plates upon these, and when the proper shapes have been 
attained, remove them from the models and solder their edges together. 

In both instances the ear is attached to the side of the head by a 
short tube upon its back fitting into the meatus, and held in place by 
a fine spring encircling the top of the head. 

Deficiency of the Cheeks and Lips. — Yery often, for the destruc- 
tion of parts of the cheeks and lips from gunshot wounds, lupus, or 
other causes, an artificial substitute can be easily made, which, when 
carefully fitted to the parts and painted flesh color, not only conceals 
the deformity, but prevents the escape of the saliva upon the face. 

The details of the process will, of course, vary according to the 
nature and extent of the parts destroyed, but the principle of con- 
structing substitutes for them is the same. First prepare a model of 
plaster of the lost portion ; from this are made analogous shapes of 
gutta-percha or metallic plates, and if necessary, the saliva may be 
received in a little gutta-percha pouch, concealed under the cravat, 
and connected by a tube of India-rubber with the substitute over the 
buccal cavity. 

In extensive disease of the upper maxillary bone requiring an arti- 
ficial palate, these plates, resembling parts of the cheek which they 
are designed to replace, may be connected with the palate by little 
metallic arms. 

Deficiency of the Palate. — The loss of portions of the palate is 
commonly due to two sources. Its absence may be owing to a con- 
genital defect, constituting Wolf's jaw, or it may be destroyed by 
certain diseases, especially those of a syphilitic nature, and lupus. 

The defect may be confined to the hard palate or extend to the 
velum, so that the natural boundary walls between the nasal and buccal 
cavities are entirely removed by the ulcerative process. In still more 
serious cases, the alveolar process and the body of the superior maxil- 
lary bone itself may be involved to a greater or less extent. 

The recuperative resources of the system are sometimes displayed 
in a wonderful manner by effecting the closing of this palatal fissure. 
This should teach us to avoid all kinds of surgical interference in such 
cases, except the occasional use of caustic, until it is certain that the 
defect is likely to be permanent. Appeal is then had to an operation 
which is often crowned with signal success ; yet there remain many 



224 APPARATUS FOR REMEDYING THE LOSS OF PARTS. 

cases not amenable to the treatment with the knife ; and in these, pro- 
perly constructed, mechanical appliances answer frequently in allevi- 
ating the sufferings and annoyances of the patient. 

In a moderate fissure of the hard palate in young subjects, the ap- 
proximation of its edges may sometimes be effected by a very simple 
and ingenious plan. Construct a palatal plate of gold with three clasps 
upon each side to catch upon the teeth, then remove a slip along its 
centre and replace it by a piece of India-rubber, which, when the clasps 
are in place, by its tension, will insensibly draw the sides of the jaw 
together. 

When all means instituted to obliterate the fissure fail, recourse must 
be had to mechanical occlusion ; the agents used for this purpose are 
called obturators. 

One of the simplest and oldest forms of an obturator is that invented 
by Ambrose Pare in 1585. It consists of a metallic plate, generally 
silver, with a piece of sponge attached to one of its sides and intended 
to be introduced through the opening in the palate into the nasal 
cavity. The absorption of moisture swells the sponge, closes the 
aperture, and effectually retains the plate against the palatal vault. 
This obturator is easily arranged, and only requires removal two or 
three times a day to be cleansed from adhering mucosities. 

A modification of this is to solder to the upper surface of the plate, 
in place of the sponge, a revolving tenon bearing at its apex wing-like 
appendages, which are intended to support the plate by catching upon 
the floor of the nares. 

All of those instruments which depend upon the pressure exercised 
by them upon the surrounding parts for support have the disadvan- 
tage of still further enlarg- 
the orifice in which they 
are placed. 

To avoid this disadvan- 
tage, and at the same time 
to prevent the secretions 
collecting in the little pit 
formed by the upper sur- 
face of the plate and the 
edges of the fissure, a drum, 
of the exact size of the 
opening and sufficiently 
deep to render the floor of 
the nares flush, is soldered 
to the plate, which is held 
in its proper situation by 
clasps catching upon the 
teeth. 

When the alveolar pro- 
cess is destroyed and the 
cavities of the antrum and 
the mouth communicate, 
the plates should be made 

Artificial palate fastening by clasps. r 




^~ m \ 



LOSS OF PARTS OF THE HEAD AXD NECK. 



225 



Fig. 145. 



larger, and possess a projecting rim upon which" any artificial teeth 
needed may be fastened. (Fig. 144.) 

The loss of the velum is a more serious concern, as regards the 
facility of procuring an effective mechanical apparatus, yet the greatest 
ingenuity has been displayed by mechanicians in supplying a substi- 
tute, and fortunately not without some success. It would be useless 
to follow the detail of, or even to mention, the numerous obturators 
invented since M. Delabarre, of Paris, first introduced his into notice, 
of which the former are for the most part modifications. 

It will be proper, therefore, only to describe, in order to give the 
reader an idea of what may be done in the way of a prosthetic sub- 
stitution for the velum and uvula, one of the best obturators. There 
is no doubt but that all the benefit which is possible to be derived 
from an appliance of this sort may, in a majority of cases, be secured 
by the artificial palate and uvula of Dr. Hullihen. It consists of: 
" 1st. A valve, made of gold plate, as thin as it can well be worked ; 
2d. A spiral spring, about an inch long, and of the size usually made 
for whole sets of teeth ; 3d. A slider, one inch and a half in length, 
and of the width and thickness of a common watch-spring; 4th. A 
plate, larger or smaller, as the case may require, stuck up in the usual 
way, to fit the roof of the mouth. The size and form of the valve are 
obtained by taking an impression of the posterior opening of the 
nares : the plate composing it should 
be stuck up in two parts, front and 
back, which, when soldered together, 
makes a hollow body of the form in 
Fig. 145, letter a. At the upper end 
of the valve a small pin is soldered, 
the point of which looks down- 
wards, and of sufficient thickness 
to fit very tightly in one end of the 
spiral spring. The spiral spring 
must be made of such a length as 
will permit the valve to rest slightly 
upon the upper surface of the rem- 
nants of the lost velum. The 
slider has a pin in the posterior 
end, looking upwards to receive the other end of the spiral spring, 
before described. The anterior end of the slider has a small button 
looking downwards ; the slider 
is attached to the plate by two 
small clasps, as represented in 
Fig. 146, b, b. The plate may 
be made to cover the entire 
roof of the mouth, when neces- 
sary ; or it may be made only 
sufficiently large to permit the 
mounting of the slider. These 
different plates, when put to- 
gether, particularly if the plate 
15 




Hullilien's artificial palate and uvula. 
Upper view. 




The same. Lower view. 



226 APPARATUS FOR REMEDYING THE LOSS OP PARTS. 

is to cover the whole roof of the mouth, make a plate of the form 
represented in Fig. 145. 

" Fig. 146 shows the attachment of the spiral spring to the valve and 
slider, c, c. The staples confine the slider to the plate, b, b — and the 
button on the end of the slider, d, by which the valve may be set back 
or forward, as desired by the patient, without removing the plate from 
the mouth. 

" Thus it will be perceived that the peculiarities of this plate are : 
First, a valve to fit to the posterior opening of the nares. Secondly, 
the attachment of this valve to a slider, by which the patient is enabled 
to adjust the valve while in the mouth, in such a way as to admit 
through the nares just the quantity of air desired. Thirdly, the 
mounting of the valve on a spiral spring, which will permit it to 
vibrate backwards and forwards, as the breath is inhaled or exhaled ; 
and also to be moved by any muscular action that may remain in the 
remnants of the lost velum, thereby answering, to a great extent, the 
purposes of a velum." 

Deficiency of the Chin. — Some of the most remarkable cases of 
loss of the chin and inferior maxillary bone are recorded in the Die- 
tionnaire des Sciences Medicales and the Bulletin de VAcademie de Mede- 
cine of the pensioners in the Hotel des Invalides, at Paris, wounded in 
the campaigns of Napoleon. 

Hutin gives an account of a soldier by the name of Frenais, who 
was wounded, in 1811, at the battle of Albufera, by a shot which 
carried away the chin. This man died in 1850, and there was ob- 
served no trace of an inferior maxillary bone until the finger was 
introduced behind the palatal process, when the remnants of the 
ascending rami of the inferior maxillary could be felt ; the tongue 
was thicker than natural, and retracted upon the os hyoides to the 
extent of a third of its length ; the deglutition was easy, but articula- 
tion was impossible without the assistance of the mask which he wore. 

H. Larrey reports a somewhat similar case : the soldier was wounded 
at the siege of the citadel of Antwerp, in 1832. He could articulate 
the vowels easily, but the consonants with difficulty, and required to 
be fed with a vessel having a long spout; the saliva escaped ex-' 
ternally in large quantities, yet did not interfere with his nutrition. 
The deformity was concealed by a mask. There are other cases of 
like character reported. 

The most that can be done for the unfortunates who are wounded 
in this manner is to conceal their disgusting disfigurement by a mask 
made of metal or vulcanized rubber, obtained from an exact model 
of the countenance, and resembling in shape the outline of the lower 
parts of the face, and properly painted. The apparatus may be held 
in place by springs or straps encircling the head. 

Deficiency of the Teeth. — The manner of manufacturing and 
fitting teeth devolves upon the dentist, and therefore requires no 
notice here. 



APPAKATUS FOE DEFICIENCIES OF THE TRUNK. 227 

SECTION II. 

APPARATUS FOR REMEDYING THE DEFICIENCIES OF THE TRUNK. 

Deficiencies of the Thoracic Walls. — Deficiency of the tho- 
racic walls is exceedingly rare, and always the result of congenital 
defect ; in those cases which have been observed, the defect was in the 
sternum, a greater or less extent of which never having been deve- 
loped, the motions of the organs below were exposed to view, afford- 
ing a rare opportunity for the observation and study of the physiolo- 
gist. 

In such cases, if it should be demanded, the construction and appli- 
cation of a defensive shield would be simple, as protection to the parts 
beneath is the desideratum. A plate of metal or other suitable light 
and hard material, slightly convex anteriorly and held upon the chest 
by straps or springs, or what would be still more secure, fastened 
by its margins to the edges of a perforation in a tightly fitting jacket, 
would answer perfectly. 

Deficiency of the Abdominal Walls. — Loss of substance of 
the abdominal walls is rare, yet more common than the similar con- 
dition of the chest. 

It may be the result of congenital defect or injury, the extent 
of the deficiency being always more considerable in the former case. 
The case of the man who was in the habit of exhibiting himself annu- 
ally before the medical classes of the different colleges is well known 
to many professional gentlemen who saw him. In this person the 
entire wall of the abdomen in the hypogastric region was absent, as 
well as the corresponding portion of the bladder, whose surface was 
exposed, its mucous membrane and the entrance of the ureters being 
in prominent view. I have seen two other persons similarly affected. 

The mechanical apparatus for such a case is also simple, consisting 
of a mask, or cap of metal or vulcanite, with an India-rubber bag 
affixed to its lower borders to receive the urine as it dribbles away, 
fitting over the pubis and hypogastrium, and secured to the body by 
straps, springs, or by an abdominal bandage to a perforation in which 
the cap is fastened by its margins. 

I have seen four cases of wounds of the abdomen, resulting from 
stabs, in which the tendon of the external oblique muscle never healed, 
the aperture being covered with a thin cicatrix which yielded to the 
weight of the bowels when the patients were in the upright position 
and allowed their protrusion. 

One of the patients was rendered comfortable by having a truss 
applied with a broad flat pad upon its anterior extremity which 
pressed upon the aperture ; one was operated upon by a surgeon who 
inserted a suture in the margins of the fissure after the skin was cut 
through ; the patient, after a narrow escape with his life, was not bene- 
fited. The other two passed from under my notice without anything 
having been done. 

The celebrated case of Alexis St. Martin is well known, and the 
mechanical appliance that would have been proper for him is evident. 



228 APPAEATUS FOR REMEDYING THE LOSS OF PARTS. 

Deficiency of the Walls of the Spinal Canal. — In the 
development of the vertebras, ossification in the bodies begins at the 
extremities of the spinal column and advances towards its middle, so 
that defect in them from arrested growth would be found in the dorsal 
region, while the laminae are ossified from the middle of the spinal 
column towards its extremities, so that imperfect development of the 
spinal canal is found in the cervical and lumbar region, and more 
often in the latter. This is denominated spina-bifida, or hydrorachitis. 

The membranes of the cord, not being supported, bulge externally 
and form an elastic tumor, varying in size from a pigeon's egg to an 
orange, or even larger, filled with the synovia-like fluid commonly 
contained in the spinal canal. 

This disease is congenital, and the only surgical interference proper, 
or at least likely to be attended with success, is compression by means 
of a properly constructed instrument resembling a truss, and furnished 
at one of its extremities with a padded metallic disk which will permit 
an accurate and uniform pressure to be exercised over the whole sur- 
face of the tumor. 

SECTION III. 

apparatus for remedying deficiencies of the upper extremities. 

Deficiency of the Arm. — It is not intended, under this head, to 
give any lengthened account of the history and construction of artificial 
arms, although the subject is one of considerable interest and utility 
to military surgeons, and to practitioners in the country. Inasmuch as 
they are often consulted upon the selection of a proper prosthetic sub- 
stitute, it may be of essential service for them to know the proper 
method of taking appropriate measurements for the artist to work by 
in turning out a nicely fitting limb, and of its construction and appli- 
cation. An additional reason for their acquiring some information in 
respect to this matter is, that they may contribute considerably to a 
patient's interest and comfort, by taking advantage of opportuni- 
ties, sometimes offered, of obtaining that length of stump best suited 
for the adaptation of the most effective and useful mechanical contri- 
vance. 

It is an interesting fact that the first effort made to provide artificial 
limbs, of which we have any accurate account, was by Ambrose Pare, 
surgeon, successively to Henry II., Charles IX., and Henry TV. of 
France. In his works, published about the middle of the sixteenth 
century, he describes an artificial arm, which was made for him "to 
his great cost and charges, by a most ingenious and excellent smith, 
dwelling at Paris, who is called, of those who knew him, and also of 
strangers, by no other name than the little Lorrain." — Les CEuvres 
d 1 Ambrose Pare, p. 677. 

The framework of the arm was constructed of sheet-iron, with ap- 
propriate springs in its interior for moving the fingers, wrist, and 
elbow, and was, therefore, very heavy, so that but few could wear it for 
a long period continuously. 

This arm, though not comparable to the artistic productions of the 
present day, redounds much to the ingenuity and humanity of the 



APPARATUS FOR THE UPPER EXTREMITIES, 



229 



Fig. 147. 



great French surgeon, who was always nobly striving to alleviate the 
misfortunes and ills of mankind, by the invention of new, or more im- 
proved apparatus, and surgical processes. 

Gotz von Berlichingen, of Nuremberg, invented an arm and hand 
made of iron, similar in mechanism to that of Pare, but much lighter, 
and so far, was a positive improvement. Beyond this, little progress 
was made until 1812, when Mr. Bailiff, of Berlin, happily constructed 
an arm and hand, weighing nearly a pound, which could seize upon small 
objects with fingers put in action by concealed gut cords fastened to the 
phalanges below, and connected above by a cord to the upper border 
of the sheath, and by the tension of which the fingers were moved by 
overcoming the resistance of small springs placed upon their palmar 
aspects. 

In 1845, Yan Peterson, of Berlin, surpassed all his predecessors in 
producing an artificial limb of extraordinary ingenuity, and was the 
subject of a report of a commission of the Academy of Sciences, Paris, 
composed of Yelpeau, Payer, Magendie, and Gambey. These gentlemen 
selected for experiment an old soldier 
who had lost both arms, and upon 
whom the artificial limbs of Peterson 
were placed as seen in Fig 147. 

The mechanism of motion consists 
of gut cords, which are fixed above to 
a corset, and below to the front of the 
forearm and to the dorsal aspect of the 
fingers, each of the latter possessing 
three articulated phalanges, and held 
in apposition by their points with the 
tip of the thumb by springs. When 
the person moves his stump forwards, 
the cord A, passing between the corset 
and forearm, being made tense, draws 
the latter up, and flexes it upon the 
arm, by which movement the hand 
may be carried to the mouth ; back- 
ward movement of the stump extends 
the arm again. The cord B is attached 
to the corset at the point marked 3, and, 
passing around a pulley in the fore- 
arm, is connected with the extending 
cords of the fingers, in such a manner 
that when the stump is abducted it 
draws upon the fingers and extends them, which immediately resume, 
by means of the springs placed upon their palmar surfaces, their 
original position of apposition with the thumb by approximating the 
stump to the chest. 

The motions of the natural limb were still further imitated by 
Charriere, of Paris, under the direction of M. Huguier. As seen in 
the figure (Fig. 148), this apparatus consists of a laced armlet articu- 
lated with a forearm of stiff leather composed of two sections, the 




Van Peterson's artificial arm. 



230 APPARATUS FOR REMEDYING THE LOSS OF PARTS, 



latter being also movably articulated with a carved, hollow wooden 
hand, provided with fingers made of steel and covered with wood, and 
sufficiently firm to retain the position in which they are placed. 

The armlet intended to embrace the stump is fastened above to a 
corset or shoulder-cap. Motion is impressed upon the limb by the 
movements of the stump acting upon a catgut cord taking a fixed 
point above the shoulder-cap, and attached below to the forearm. By 
abducting the stump, the cord A flexes the forearm, and through this 
movement the wrist also by means of the cord D extending between the 
eccentric projecting posteriorly, from the inner hinge of the elbow, and 

Fig. 149. 





Mechanism of pronation of Charriere's artificial arm. 

the anterior margin of the hand, into which 
it is inserted at F by means of a short spiral 
spring. "When the stump again resumes its 
position by the side of the chest, and the 
cords A and D are relaxed, the elastic bands 
G extend the forearm, and at the same moment 
the spiral spring extending between the points 
I and H causes the hand to execute the same 
movement. By pressing upon one of the 
projections J, with the other hand or hip, the 
movements of pronation and supination may 
be impressed upon the limb. There is also an- 
other provision made for these motions by a mechanism attached to the 
external hinge of the elbow at M, Fig. 149 ; it consists in an eccentric, 
N, moved by a sectional cog-wheel, M, that it may be made to complete 
one whole revolution by the complete flexion of the forearm ; to the end 
of this eccentric the cord is fastened above, and, passing downwards, 
enters an aperture in the forearm, goes around the pulley P, and finally 
is terminated by being attached to one of the cross-bars of the forearm 
at the point T, so that when the forearm has executed half the movement 



Artificial arm of Charriere. 



APPARATUS FOR THE UPPER EXTREMITIES. 231 

of flexion the eccentric also completes half a revolution, and ascends to 
a position parallel with the arm, drawing the cord o to its extreme degree 
of tension, and necessarily supinating the forearm. The flexion being 
still farther increased, the eccentric descends towards its original posi- 
tion, relaxing the cord o, and permits the spiral spring s, passing around 
the pulley B and attached to the cross-bar at T, to bring the arm into 
pronation again. In extension of the limb, again, the eccentric first 
supinates and then pronates the forearm as before. By the same 
mechanism extension of the fingers may be produced. 

Another artificial limb, equalling the preceding in ingenuity, was 
invented by M. Bechard, and is thus described by Bigg : — 

"The point of support is a laced sheath carried by two iron splints 
adapted to the arm. The articulation of the elbow presents nothing 
particular. The forearm and hand consist of three movable pieces of 
hollow wood. 

"1st. The upper portion is fixed by means of the two splints which 
serve for the articulation of the elbow and terminate there. 2d. The 
second portion, entirely of wood, corresponds to the lower two-thirds 
of the whole length ; it carries at its upper part a movable chariot, 
rolling by means of bone castors which slide on a circular plate of 
iron, so that the movements are very smooth. This arrangement 
allows this portion to move on the upper one through a quarter of a 
circle, and this motion, being transmitted to the whole lower part, 
simulates the rotation of the limb outwards. 

" The limb is maintained in the normal state of pronation by a spiral 
spring fixed at the top of the piece in the centre of the chariot, the 
permanent action of which acquires all its force when all pulling 
ceases. To explain this mechanism more fully, a single cord of gut, 
starting from the top of this piece and communicating with the chariot 
by means of two small pulleys, goes up along the amputated limb, 
passes behind the shoulder, and reaches obliquely the circular band 
of the trowsers at the braces of the opposite hip. 

""When the arm is abducted, this cord, being stretched, acts on the 
chariot, which, rotating on its axis for a quarter of a circle, carries 
with it all the lower part of the apparatus, rotating it outwards ; that 
is to say, supinating it. When, on the contrary, abduction is replaced 
by adduction, the spiral spring we have mentioned gets in action, and 
brings back the arm by a reverse movement into its normal position ; 
that is pronation. 

" The second piece, which performs this movement of rotation over 
a quarter of a circle, carries in the centre of the upper plate which 
terminates in a straight rod, which descends through its interior in 
the direction of its axis. This rod, which for a sufficient length is 
surrounded by an endless screw, supports, on a level with that screw, 
a horizontal box, which it raises during supination and lowers during 
pronation. The box itself carries at its extremities two parallel 
branches of iron, which terminate a little above the wrist-joint in two 
transverse metallic button-holes. These button-holes enter a segment 
corresponding to each of them, cut out of the iron plate which termi- 
nates this second piece ; they are connected with the pulling of the 



232 APPARATUS FOR REMEDYING THE LOSS OF PARTS. 

fingers. As the action of the endless screw on the box is manifested 
during rotation, the two branches which terminate it, rising during 
supination, act on the extensor tendons of the fingers and bring them 
into action. 

" The third improvement is much more important, and consists in 
this : The hand which is at the end of the artificial arm being exposed, 
when used, to all kinds of frictions, gets easily dirty; and then it is 
necessary, according to circumstances, in order that the imitation be 
perfect, that it should be naked or gloved. 

" After a good many trials, M. Bechard discovered a method of un- 
hooking the wrist, by means of a pressure made with the other hand 
on a button hidden under the coat-sleeve. It will be easily conceived 
that much patience was required in order to succeed in combining a 
system admitting of the arm being completely taken to pieces, of 
changing the hand, and of instantaneously resembling the actions of 
the extensor and flexor tendons. With this view, the union of the 
wrist with the second piece of the arm, the mechanism of which has 
been described, is effected a little above the place occupied by the 
radio-carpal joint below, by means of a double-toothed pinion enter- 
ing a mortice hollowed out of the lower surface of the second bra- 
chial piece. On each side of this pinion are two prominent buttons, 
with conical heads above a smaller neck, which correspond to the 
pulleys of the fingers, divided into two bundles. Both parts are joined 
together by making the pinion obliquely enter the mortice ; the wrist 
is then made to rotate over a quarter of a circle, in the same way as a 
bayonet is fixed ; and when the rotation is completed, the two metallic 
buttons come and hook into the two horizontal button-holes, which ter- 
minate the two branches of the mobile screw-box indicated above. 

" Lastly, the fingers, carefully carved out of wood, show no mechan- 
ism externally ; all is in the interior. M. Bechard does away with the 
cord of gut as the acting force, and with spiral springs as the resisting 
force. A simple flexible steel plate, placed inside, and half flexed, is 
arranged in such a manner that by pulling on the upper part it pro- 
duces extension, and the reverse movement, when it ceases to act. 
The thumb alone is moved (by means of two reflecting pulleys con- 
necting it with the common traction) in such a manner that when the 
fingers are extended it performs the same movement, and is, besides, 
abducted, in order to return to the flexed position, and is abducted 
when at rest. Furthermore, care has been taken, not only to put in 
its anatomical place the metacarpo -phalangeal articulation, but also 
to imitate the longitudinal grooves which separate them ; this has 
never been done before, and detracted from the shape of the hand, ren- 
dering it unnatural and ungraceful." 

"The preceding description applies to an apparatus intended to 
replace the forearm, amputated below the elbow." 

If it is required to replace a limb amputated through the lower part 
of the humerus, or through the elbow-joints, an armlet is added which 
embraces the upper part of the opposite arm. This arm-piece serves 
to give attachment to a traction string, which passes transversely from 
one shoulder to the other, and, after coming down along the appara- 



APPARATUS FOR THE UPPER EXTREMITIES. 233 

tus, ends at the upper and inner part of the forearm. This string is 
destined to produce flexion of the elbow. It is moderately tense in 
the normal position of a man who is standing, and acts when the 
sound arm is abducted ; on the two points of attachment becoming 
more distant, the elbow is flexed. 

These arms now described are models of mechanical ingenuity and 
elegance of finish, and have been the ground work upon which Euro- 
pean mechanicians have labored to obtain other less complicated and 
less expensive limbs, so as to bring them within the reach of all 
classes of persons who have had the misfortune to lose an arm. 

The mechanical and artistic ingenuity of America has not lagged 
behind that of our transatlantic brethren. Artificial arms are now 
manufactured here which combine both exquisite workmanship, and 
all the really useful functions which such a mechanism can perform, 
at a comparatively moderate expense. 

The artificial arm of Mr. Gildea, of Philadelphia, for amputation 
below the elbow, is an excellent contrivance ; and for durability, neat- 
ness of finish, and efficiency cannot, I think, be surpassed by auy yet 
invented ; its mechanism is simple, and not liable to get out of order ; 
it is modelled in exact imitation of the natural limb ; made of willow, 
and elegantly enamelled. At the metacarpo-phalangeal articulations 
the fingers are solidly connected together by a transverse bolt, which 
allows antero-posterior motion only; the fingers are carved from a solid 
piece of wood, and are in a position of semi-flexion, the index oppos- 
ing the thumb, and the little finger forming a sort of a hook; the 
thumb is movable both at the metacarpo-phalangeal and phalangeal 
joints. 

The mechanism of motion consists of a metallic rod, which is con- 
nected at its lower extremity to the base of the middle finger, and at its 
upper to the end of a short lever, which has a fulcrum at the centre of 
the hand, and projects towards its ulnar border, where a spiral spring 
connects it with the base of the little finger. Parallel with this lever, 
and above it, is a second lever, fastened by a fulcrum, at one end to 
the ulnar border of the hand ; a little to the outer side of this point 
there is a tenon, between which and the inner extremity of the second 
lever a piece of wire extends, coupling the two levers together; a 
short distance from the tenon, the upper end of the extensor cord of 
the thumb, which is of catgut, is attached. A long steel strip passes 
from the outer extremity of the upper lever, externally, through a 
perforation upon the radial border of the forearm, and is extended to 
the upper arm-band by a strap and buckle ; the thumb is kept in con- 
tact with the index finger by a steel spring formed of several short 
pieces of watch-spring superposed. The arm is held on the stump by 
two lateral metallic straps, extending along each side of the arm, and 
connected above by two padded straps. 

When the arm is in use, by giving proper tension to the traction 
cord the person has only to extend the stump to expand the fingers 
in grasping objects; the traction-cord acts upon the upper lever, 
which draws directly upon the extending cord of the thumb, and at 
the same time forces the radial end of the lower lever with the metal- 



234 APPARATUS FOR REMEDYING THE LOSS OF PARTS. 



lie rod above-mentioned downwards, and as all the fingers are solidly 
connected with the middle finger, to which the rod is attached, they 
must be extended. If the stump of the forearm is now flexed, the 
traction cord ceases to act upon the levers, the thumb and index finger 
will be approximated by the springs connected with them, and seize 
the object, whatever it may be, between them. 

In this manner a person will be enabled to pick up a pockethand- 
kerchief, or hat, a paper, or other such objects; a pen* may also be 
held in the hand, and with a little practice the person may write very 
well with it. A basket or satchel, or anything having a similarly 
arranged handle, may be carried upon the hook formed by the little 
iinger. 

Mr. Kolbe, of this city, is also the inventor of a meritorious artifi- 
cial arm, the mechanism of motion of the fingers consisting of metallic 
levers acted upon by a single cord of traction ; the fingers have the 
same number of joints as are found in the natural hand. It should be 
observed, however, in regard to this point — the introduction of nume- 
rous joints in the fingers — that it adds little, if any, to the utility of 
the hand, while, at the same time, it possesses the very decided draw- 
back of requiring a larger number of levers, which add much to the 
expense and complexity of the mechanism. To overcome the increased 
amount of friction of the levers, greater power must also be applied 
upon the traction cords, which in limbs fitted to short arm stumps 
very much impairs their utility and range of motion. 

We have now considered the more complex and expensive artificial 
arms requiring the greatest amount of mechanical and artistical ability 
in their fabrication, and which must of necessity be almost, if not 
entirely, within the reach of the wealthier classes alone. It remains 
for us to consider briefly those prosthetic contrivances which are 
simple in construction, and within the means 
of all persons. 

In case of disarticulation at the shoulder- 
joint, an artificial limb can be constructed and 
affixed to a shoulder cap or a corset; being 
modelled in exact imitation of the remaining 
natural limb, it will restore symmetry to a per- 
son's appearance, but little natural motion can be 
obtained. The limb should not be straight, but 
possess that graceful curve, Fig. 150, which the 
natural arm assumes, hanging in its own as- 
sumed position by his side, when a person 
stands erect. For the poorer classes who de- 
pend upon mechanical pursuits for a livelihood, 
an arm without a hand, and terminating at the 
wrist with a metallic screw plate to which many 
useful implements may be affixed, will be the 
most useful. For example, a porter or messen- 
ger might find great assistance in a hook for carrying bundles, a basket, 
or any such articles. Should the amputation have been performed 
between the shoulder and elbow, a stump will be left which will per- 



Fig. 150. 




The common artificial arm. 



APPARATUS FOR THE UPPER EXTREMITIES. 235 

mit the artificial member to be attached much more easily by shoulder 
and thoracic bands, and at the same time be much more comfortable 
to the wearer, who will then be able to dispense with that part of the 
mechanism required upon the chest, and to which an arm adapted to 
a disarticulation at the shoulder must be affixed. 

Where the amputation is made through the forearm and a freely 
mobile stump obtained, greater latitude of motion can be impressed 
upon the artificial member, and the varied occupations in which a 
person may engage, in consequence, will enable the physician to direct 
many useful instruments to be affixed to the screw-plate. Such, for 
example, as a knife or fork, a three-pronged hook for driving, as seen 
in Fig. 151, or indeed any implement that can be used under these 
circumstances, and which may be demanded by special trades or 
callings ; even a pen may be used when held by a tube supported 
upon a stem projecting from the plate, or a pair of forceps. These 
mechanical contrivances may also be fastened to the palm of the 
• hand, should it be desired to have one in connection with the arm. 

Fist. 151. 




Arm with, driving hook attached. 



The sheath must be neatly moulded to the forearm, and may be 
held in place, if there is sufficient length of leverage, by two lateral 
bands connecting its upper border with a band surrounding the 
arm ; or if the amputation is nearer the elbow, two jointed lateral 
stems, connected above with a padded metallic band embracing the 
arm, will afford more security. 

A still more natural appearance and a greater range of useful move- 
ments may be obtained by giving to the hand movements somewhat 
approximating those possessed by the natural wrist and fingers. A 
glance at the anatomical arrangement of the natural constituents of 
the wrist-joint will render it evident that the imitation must necessarily 
be rude and imperfect ; yet this can be accomplished to such a degree 
as to render the artificial movements of considerable assistance. Strictly 
the wrist possesses but four movements : adduction, abduction, flexion, 
and extension ; and the apparent circumduction possessed by it is ac- 
complished from the facility with which the hand passes from a position 
of flexion or extension to those of abduction and adduction ; there is no 
rotative motion in this joint. The normal motion possessed by the 
thumb-joint is flexion and extension with a very slight lateral move- 
ment; the thumb derives its extended and varied range of motion 



236 APPAKATUS FOR REMEDYING THE LOSS OF PARTS. 

principally from the first carpo-metacarpal articulation, which is really 
in some degree susceptible of all the motion of an enarthrodial joint. 

The mechanical provision in artificial arms permitting rotative 
motion in the wrist is extremely simple, consisting of a keyhole plug 
fastened to the wrist-plate and fitting a corresponding keyhole upon 
the arm-plate; the range of motion of the hand upon the forearm 
being regulated by a spring in the lower part of the latter catching in 
a series of indentations upon the wrist-plate. Thus any desired rota- 
tive position may be impressed upon the hand at the will of the per- 
son. Extension and flexion of the hand may be accomplished with a 
cup-like depression in the wrist-plate, with which a spherical knob 
upon the arm -plate articulates, and is secured in accurate contact with 
it by a little pin connecting its apex with the bottom of the concavity. 

No construction yet invented is even a fair imitation of the natural 
movements of the thumb, which are numerous, varied, and important, 
and in their perfection are confined to man alone. Other animals, it 
is true, enjoy some share in them, yet they cannot approximate the 
tips of the fingers and thumb with that accuracy and firmness essential 
to the full performance of many digital operations executed by man. 
It is provided with larger muscles and a greater number than any of 
the other fingers. The muscles act upon its carpo-metacarpal and 
two digital joints in divers manners and directions, and thus it can be 
readily understood how difficult it is, with springs and cords, to pro- 
duce even a partial similitude to the natural actions. Indeed, little 
more than a spring can be placed in the centre of the thumb to retain 
it continuously in contact with the ends of the fingers : so that any 
object placed in between them will be grasped and held in pretty 
much the same manner as it would by a common spring clothes-pin. 

Though these mechanical arrangements in the wrist and thumb- 
joints are exceedingly rude and imperfect when compared with the 
natural organ for the movements of these parts, they yet contribute 
somewhat both to the natural appearance of an artificial limb and its 
utility. 

The efforts of surgeons latterly in amputating through the various 
joints of the hand, preserving just as much of that part as the nature 
of the injury will permit, has resulted in some glorious results for 
conservative surgery. Even a single finger will do good service, or 
a part of a finger, when it is practicable to preserve this much, will 
contribute to a patient's welfare. Many digital operations may be 
satisfactorily performed by the thumb and index or any one of the 
other fingers, so that the conservation of the thumb and a digital oppo- 
nent is of so great importance to a patient that it should always 
engage the surgeon's earnest attention while performing these opera- 
tions about the joints of the hand. 

Little more can be done by prosthesis in such cases than to restore 
the symmetry of the part, which may be satisfactorily accomplished 
by moulding a sheath of leather or other suitable material to the 
stump of hand to which the missing member may be readily affixed. 
The deformity arising from the loss of a single finger can be made to 
disappear by having a glove of an appropriate size to fit the wearer, 



APPARATUS FOR THE LOUVER EXTREMITIES. 237 

and to which a false finger corresponding to the one lost may be 
attached. 

Art still further endeavors to bring nearer to perfection these arti- 
ficial substitutes by conferring upon them some degree of that softness 
and elastic feeling of the natural member. This has been to some 
extent accomplished by means of a coating of India-rubber, which, 
however, does not possess that smoothness and warmth to complete 
the deception of the sense of touch. 

From the foregoing consideration it will be seen that it is not an 
indifferent matter as to the place at which the amputation has been 
effected, as regards the ease with which an artificial limb may be 
attached, or the amount of utility such a mechanism possesses. It has 
been seen that, when disarticulation has been performed at the shoulder 
or the amputation performed near to it, the arm must of necessity be 
attached to some contrivance upon the chest, and thus complicate the 
mechanism and inconvenience the patient; at the same time there is 
no stump to exercise a leverage upon the arm and thus extend its 
range of motion. 

Of amputation between the arm and elbow, the point most con- 
venient for the adaptation of a prosthetic substitute is that at the 
junction of the middle with the lower third, though with care an arm 
may be made for a stump of any length. Perhaps the mechanical 
difficulties culminate in an amputation through the elbow-joint, which 
will give a large and broad stump liable to be pressed upon injuriously 
by the lower part of the arm sheath, and also to interfere with the 
mechanism of the elbow. 

Two-thirds of .the length of the forearm will give a gently tapering 
stump to which an arm may be fitted with ease, and possess as great 
a range of movements by the action of the stump as can be attained 
by any other length. More stump than this will embarrass the 
motions of the wrist-joint, and occasionally be the source of annoy- 
ance to the patient by pressure of the sheath upon its extremity. 

SECTION IV. 

APPARATUS FOR REMEDYING DEFICIENCIES OF THE LOWER EXTREMITIES. 

Deficiency of the Leg. — The necessity for an artificial substitute 
after the loss of a lower extremity is far greater than for that of an 
arm ; the loss is more seriously felt when a person is dependent upon 
his avocation for maintenance, and is compelled to make active exer- 
tion in the execution of the duties it imposes upon him. Should the 
free use of both hands be necessary, he will also find the amount of 
assistance they afford materially diminished if compelled to hobble 
about upon a crutch, which imperiously calls for the service of one of 
his hands. So we might, in such a case, really say that the loss of a 
leg also implies that of an arm, which, hitherto peculiarly devoted to 
the performance of varied and important actions executed by this 
organ, is now turned away into a new channel, and assumes a partici- 
pation in the office of progression. The ordinary crutch was, of 
course, the first kind of mechanical assistance that would have natu- 



238 APPAEATUS FOE EEMEDYING THE LOSS OF PAETS, 



rally suggested itself to do away with the accompanying inconveni- 
ences, and incapacity of moving about, yet at a very early period 
artificial legs were used, and this suggests the superior importance in 
which the construction of legs over arms was held by the ancients, as 
they have transmitted absolutely nothing concerning the preparation 
of the latter, as has already been stated in the previous section, while 
several authors describe artificial legs. 

If we first consider the mechanical circumstances under which a 
natural leg is placed, we shall be better able to appreciate the ad- 
vantages and disadvantages of the various kinds of prosthetic appa- 
ratus destined for the lower extremity, and the conditions which they 
must fulfil in order to meet the requirements and necessities of a 
person compelled to employ them in the act of progression. The 
human body in health, standing erect at ease, has the heels approxi- 
mated and the toes turned outwards, so that the axis of the foot cuts 
the line of direction of progression at an oblique angle, and has its 
various parts distributed in equilibrium about a central axis or line A D, 
of gravity, which, starting from the vertex of the head, falls between 
the occipital condyles, passes thence downwards to the tip of the coc- 
cyx, and terminates at a point upon the plane upon which the person 
stands, midway between the two heels. This line of gravity remains 
unchanged as long as the equilibrium is undisturbed ; but the moment 
the person changes his position, as in walking, the equilibrium is 
altered, and necessarily the line of gravity, which is shifted alternately, 
as the weight of the body is borne first upon one leg 
and then upon the other, to positions represented 
by the dotted lines A E, A c (Fig. 152). In this 
manner, while the equilibrium of the body is estab- 
lished around an axis passing from the vertex 
through the ischium and coinciding with the axis 
of one of the lower extremities to the sole of the 
foot, the opposite extremity swings forward after 
the pelvis is thrown forward by the extension of the 
limb to that position necessary in taking a step, by 
the force of gravity alone ; so that really little or no 
muscular force is expended except that consumed in 
flexing the leg to an extent requisite for raising the 
foot from the ground. 

The experiments of the Webers conclusively prove 
that the legs of a dead body, held in an upright 
position and moved forwards, may be made to exe- 
cute the movements of those of a living person in 
progression, if a substitutive force for that exerted 
by the muscles in lifting the feet from the ground 
be employed. 

Of the four joints of the lower extremity, the hip, 
knee, ankle, and first metatarsal phalangeal articula- 
tion, which in an especial manner contribute to the ease and efficiency 
of walking, the ankle-joint, including the connections between the tarsal 
bones, deserves especial attention, as it is the difficulty of imitating 



Fig. 152. 




APPARATUS FOR THE LOWER EXTREMITIES. 239 

their movements which has hitherto been in the way of the surgeon in 
devising an artificial leg possessing life-like actions. The tibio- 
astragalal articulation permits flexion and extension with a slight 
degree of rotation, while the articulations between the tarsal bones 
themselves confer most of the power of abduction and adduction and 
rotation enjoyed by the foot. With this extended range of motion at 
this point, the muscles of the lower extremity bring with ease the 
body in equilibrium about the line of gravity of the limb, and there- 
fore this joint must contribute largely to rapid and graceful walking. 
Were this otherwise, as indeed sometimes happens in diseases of the 
bones of the foot and consequent anchylosis of the joints, and the 
movements of the ankle restricted to simple flexion and extension, for 
instance, the muscles could not readily balance the body when sup- 
ported alternately upon one leg and the other in walking, and the gait 
would then be awkward, slow, and shuffling. The weight of the body, 
when a person stands upon one foot, is sustained in the direction of a 
line running through the femur, acetabulum, tibia, and the arch of the 
foot, by these osseous pillars placed in the interior of the lower ex- 
tremity. The centres of the knee and ankle-joints are placed some- 
what behind this line, so that when the limb is straight the weight of 
the body adds to their strength, and relieves the muscles greatly in 
sustaining the body erect. 

With these mechanical conditions under which a natural limb is 
placed in supporting the weight of the body, either at rest or in the 
act of walking, impressed upon the mind, we are prepared to under- 
stand how far the various artificial substitutes do and can fulfil their 
purposes when the loss of a limb compels a person to seek their 
assistance. Those persons who have paid much attention to this 
subject, and devised such apparatuses, have been more or less suc- 
cessful in proportion to their knowledge and apprefciation of the ana- 
tomical structure and physiological actions of the natural limb. 

Commencing with the foot, we shall see that the prosthetic apparatus 
for it, although contributing somewhat to progres- 
sion, are more especially employed to correct de- Fig. 153. 
formity. The class of operations requiring them are 
amputations and resections : among the former are 
ranged Syme's, Chopart's, Hays' and PerigofFs ope- 
rations ; and among the latter the removal of the 
astragalus or os calcis separately, or both together, as 
in the process of Mr. T. Wakely, Jr. When there 
is a sound and well-formed stump obtained by any 
of these processes, which will sustain the weight of 
the body without pain, the walking of a person so 
maimed may be materially assisted by the shoe 
represented in Fig. 153, which has a sole of suffi- 
cient thickness to make up any difference in the 
length of the two limbs, and supports the parts by 
lacing high up upon the ankle. 

The addition of an artificial foot is a question 

o •-, -,, , - ,. _ , * „ Shoe after amputation 

ot considerably more mechanical difficulty, from atankie. 




240 APPAEATUS FOR REMEDYING THE LOSS OF PARTS, 



Fig. 154. 




Apparatus for amputation through, the foot. 



the fact that there exists great difficulty in fastening the shoe to the 
stump in such a manner that it will not press upon its anterior sur- 
face, which must occur if the artificial foot is placed against it, every 
time the leg bends forwards in locomotion. To prevent this upward 
action of the artificial foot, it is simply necessary to provide a metallic 
sole, upon the upper surface of which there is a padded socket to receive 
the stump and part of a foot, in exact imitation of the lost portion of the 

natural organ, and having a toe-joint. 
Its posterior extremity is deeply 
grooved to fit accurately the anterior 
surface of the stump, to which it is 
fastened by straps. To the metallic 
plate there are fastened two steel 
rods, running up the leg to the 
knee, one upon each side, provided 
with bands, &c. to secure the ap- 
paratus in place; corresponding to 
the ankle-joint, there is placed a 
stop-joint, which prevents the ante- 
rior part of the foot being flexed at 
more than a right angle with the 
leg. When the artificial substitute 
is securely connected with the leg, 
and the patient attempts to walk, as the heel is lifted the stop-joint 
sustains the foot at right angles to the leg until the pressure comes 
upon the toe-joint, which yields immediately, and thus imparts a 
natural motion to the step without lifting the front of the foot suffi- 
ciently to throw its upper and back part against the stump. 

If the toes or anterior part of the metatarsus are simply removed, 
an ordinary shoe, with its anterior portion properly padded, will serve 
the purpose of concealing the deformity. The same plan may answer 
also after Hey's operation ; should it not, however, in consequence of 
the tilting of the artificial part against the end of the stump, the pre- 
vious plan must be adopted. 

After the resections above mentioned, the only prosthetic apparatus 
required will be a common shoe with a sufficiently high heel to make 
up the difference of length between the injured and sound limbs. 

In the foregoing cases the weight of the body is borne upon the 
stump ; but when the amputation is performed between the knee and 
ankle, this cannot be done, however skilfully the operation may have 
been executed, or however successful it may have been in securing a 
well-covered and fleshy stump. In any case, the weight of the body 
would soon cause the soft parts to be absorbed, and the end of the 
bone to protrude. It scarcely matters much how great a mass of 
muscular substance may be placed over the bone, for in the course of 
a few months the tissue will become atrophied and converted into a 
dense cellulo-fibrous mass, and the end of the bone rounded off and 
conical. As this is the natural method observed in the subsequent 
modelling of the extremity of an amputated limb, it would seem 
that too much stress has been placed upon the importance and supe- 



APPAEATUS FOE THE LOWEK EXTREMITIES. 



211 




The common socket-leg. 



riority of certain processes over others in securing trie best stump for 
an artificial leg ; when the truth really is that no greater thickness of 
tissue will be found over the bone after the lapse of a twelvemonth, 
in operations with voluminous muscular flaps, than 
after a circular operation with flaps of skin and Fi g- 155 - 

cellular tissue. In either case, if the stump is well 
rounded and sound, it will suffer with impunity the 
amount of strain brought to bear upon it in em- 
ploying an artificial leg. As stated above, the 
natural limb has but one point of bearing, that is, 
in its axis or line of gravity, but this cannot be 
imitated in adapting a prosthetic apparatus, from 
the stump being intolerant of pressure; so that the 
surgeon is compelled to make a point of bearing of 
the entire outer surface of the stump, by inclosing 
it in an accurately fitting sheath of stout leather or 
willow. This diffusion of pressure over as great 
an extent of surface as possible should always be 
kept in view in making artificial socket limbs of 
any description, for it is manifest that the local 
effects of pressure or force of any kind must di- 
minish in the ratio of its diffusion over the surface 
upon which it acts. The common socket-leg (Fig. 
155) is constructed in this manner, with an accu- 
rately-fitting wooden sheath, into the bottom of 
which a pin of the same material is inserted, to 
make up the distance between the stump and the ground. The leg 
is prevented from falling off by the lateral straps connected with a 
leathern thigh-band. A still more seemly artificial leg (Fig. 156) is 
manufactured, which, instead of the pin 
attached to a socket, has a foot with Fig. 156. 

movable ankle and toe joints, and is 
fastened in the same manner as the 
socket-leg. This point will, however, 
depend much upon the length and con- 
dition of the stump, which, if but three 
or four inches long, will require two 
lateral metallic stems joined at the knee, 
and fastened above to a metallic thigh- 
band, that the stump may not be drawn 
from the socket while the person exe- 
cutes the act of locomotion. . Equally 
as great an evil is a too lengthy stump, 
the end of which is constantly liable to 
rub against the inner surface of the 
sheath, and cause the wearer of the leg 
constant pain or uneasiness while mov- 
ing about. This rubbing often occurs upon the anterior surface of 
the tibia, and may demand that that part of the wall of the socket 
corresponding to it be removed, so that the end of the stump may 
16 




Artificial leg for amputation brslow the 
knee. 



242 APPAKATUS FOB REMEDYING THE LOSS OF PARTS 




Apparatus for extending a contracted stump. 



have unrestrained play. Again, where the stump is badly healed 
and tender, and cannot bear the pressure of the socket, the artificial leg 

must be still further modified, so 
Fi g- 15 ?. as to receive the weight of the 

body upon a leather cap fitting 
inside of the socket and closely 
embracing the stump as high up 
as the tubercle of the tibia. 

It sometimes happens, also, from 
the shortness of a stump, or other 
cause, that it remains after the 
lapse of some time in a perma- 
nently flexed position, requiring, 
before any of the above forms of 
prosthetic apparatus can be had 
recourse to, that it be extended 
and restored to some degree of 
mobility. To accomplish this, the 
simple apparatus seen in the figure 
(Fig. 157) may be employed ; it 
consists of two lateral -join ted metallic rods, connected below by a 
metallic gutter fitted to the posterior surface or calf of the leg, and 
extending above the knee. A strong cloth band, crossing the patella 
and attached to the two rods upon either side, serves the purpose of a 
fulcrum. The extending force is applied to the upper extremities of 
the bars by means of an India-rubber band passing between them 
and the thigh. , • 

Another form of artificial leg (Fig. 158) for a stump below the knee, 
is the common wooden pin or "box leg." It consists of a wopden 
frame widely grooved below to accommodate the knee, 
and of two lateral side pieces; the external, slightly 
curved backwards, reaches from the knee to the crest of 
the ilium, and the internal, halfway up the thigh ; from 
the bottom of the socket a pin projects, and makes up 
the interval between the knee and the ground. 

The apparatus is fastened to the body by a strap 
passing around the waist, and the outer and upper end 
of the side piece; to give the leg stability and insure 
firmness in stepping, the pin must be mortised squarely 
at the knee, and with as broad a base as possible. To 
prevent the projection of the superior extremity of the 
leg backwards when the person sits down, a joint may be 
placed upon it at a point corresponding to the articula- 
tion of the hip. 

fl ■ U M. de Beaufoy has invented a foot for the wooden 

pin worn by the pensioners at the Invalides at Paris. 
The advantage of this improvement, says Guthrie, is 
"that whereas a common wooden pin has only one 
point of support, and consequently the body is obliged to raise itself 
so as to describe an arc of which the end of the wooden pin is the 



Fig. 158. 




The "wooden 
pin." 



APPAEATUS FOR THE LOWER EXTREMITIES. 243 

centre, the curved foot acts like a series of levers, each successive 
point of it being a fulcrum." 

The weight of the body with this leg is borne upon the knee, and 
is transmitted to the ground in the normal line of the centre of gravity 
of the limb. 

For amputations of the thigh we will not find as great a variety of 
artificial limbs, from the circumstance that they present us with a 
stump of a pretty uniform character as to length and shape ; yet it is 
here that we find the greatest efforts of mechanical ingenuity displayed, 
and the greatest number of methods by which the mechanical require- 
ments of an artificial leg are fulfilled. The mechanical conditions 
under which a natural leg is placed while the function of locomotion 
is being executed have already been briefly alluded to, and it was 
stated, then, that the weight of the body in changing its position in 
walking was thrown alternately upon one and the other leg, and sup- 
ported in a line of gravity running through the acetabulum, femur, 
and bones of the leg; that there was but one point of bearing, and that 
was central ; that the muscles were chiefly concerned in raising the 
foot from the ground, and that the gravitation of the limb carried it 
forwards to its destined position. 

Prepared with these facts, we can now inquire how these conditions 
may be realized in a prosthetic apparatus : — 

1st. As to the points of support or bearing: We cannot mechani- 
cally restore that part of the line of gravity represented in the natural 
limb by the femur, and destroyed with the removal of the leg ; as 
the only way to do so would be to make the end of the divided bone 
a point of pressure by establishing again the same length of bony 
column which supports the body naturally (which, as we have already 
shown, is impossible). The only way, then, is to inclose the stump in 
a sheath, technically called " a bucket," to diffuse the pressure over its 
surface to as great an extent as possible, and thus to transmit the 
weight of the body to the ground, not through a central axis of sup- 
port, but by a circumferential support, that is, by the walls of the 
bucket; which is just the reverse of the natural condition of things, 
but an imposed necessity. Were there a projecting point about this 
central axis capable of bearing pressure, and against which the upper 
edge of the bucket might rest in supporting the body, the result would 
be much more satisfactory than any we now obtain by pressure upon 
the surface of the thigh stump. It has been suggested that the ischium, 
which lies posterior to this line, might serve as a circumferential point 
of bearing ; and with this view the upper edge of the bucket of some 
artificial legs ascends to it, and the plan answers exceedingly well. 

2d. The provisions for the imitation of the natural action of the joints 
have until lately been very unsatisfactory; and it was not until the in- 
vention of Dr. Bly's leg that little was left to be desired in this direction. 
An examination of the structure of the knee and ankle-joints teaches 
us that their centres lie a little in the rear of the line of gravity of the 
limb, estimated to be a half an inch for the knee and three-quarters of 
an inch for the ankle, so that, when the limb is straight, the greater the 
weight transmitted to them the more firm they are. So in an artificial 



244: APPARATUS FOR REMEDYING THE LOSS OP PARTS 



limb, the articular centres or bolts should be placed in the rear of this 
line the same distance, that when the person rests the weight of his 
body upon it, the joints will afford a firm and secure support, and be 
reinforced just in proportion to that weight. 

3d. The varied actions of the muscles of a natural limb in the exe- 
cution of all their functions cannot be fully imitated in any artificial 
mechanism, but those chiefly active in locomotion may be to a reason- 
able practical extent. As to the knee-joint, as the limb swings forward 
by gravity and extends the leg, really no mechanical contrivance for 
this purpose is at all required, but with the ankle it is quite otherwise : 
here some provision must be made for the flexion and extension of the 
foot, else in walking the toe would either be constantly catching against 
every uneven spot or projecting point upon the ground, or approaching 
the front of the leg, the person would walk upon the heel alone, if the 
weight of the body did not bring the toe down, as it would in the 
latter case, with a heavy stroke. 

The foot must be then secured at right angles to the leg, in such a 
manner that, after being either flexed or extended, it will spontaneously 
and promptly return to its original position when the force is removed. 
This can be accomplished in several manners, with elastic cords, spiral 
springs, or gut cords fastened to an elastic metal slip placed in the sole 
of the foot. India-rubber is an exceedingly valuable material in the 
construction of artificial limbs, and is employed to imitate the action of 
muscular fibres, from its capacity of contracting promptly after being 
stretched ; but after being used some time, it loses this indispensable 
property to a greater or less extent, and is then apt to break. Dr. Bly 
happily overcame this objection by availing himself of the expansive 
power of railroad car-spring rubber, after compression, in which manner 
it cannot be injured, however much it may be used.. Its application 
will be seen hereafter. 

Spiral springs are arranged in the ankle in the manner seen in the 
figure (159), one in front of the instep and another in the position of 

Fig. 159. 




Diagram showing the mode of arranging spiral springs in the ankle and their action. 

the tendo-Achillis. Although possessing the valuable properties of 
exercising expansive force when compressed, and contractile force when 
extended, they are inferior to the rubber springs used in the Bly leg, 



APPAEATUS FOR THE LOWER EXTREMITIES. 245 

which give a more uniform and natural movement to the limb ; they 
do not become weak by use, nor yet do they rust or produce any 
roughness or creaking noise. 

It now remains for us to consider the prosthetic apparatus at pre- 
sent in use, and see how the above detailed mechanical principles are 
carried out in their construction. The simplest of the artificial legs 
is that composed of an accurately fitted "bucket," the upper margin 
of which should abut against the ischium, and of a wooden pin to make 
up the distance to the ground: it is fastened to the person of the 
wearer by a strap passing around the waist. A more convenient limb 
than the above may be obtained by providing it with a hinge corre- 
sponding with the knee, and controlled by a spring check-slide, placed 
upon the inner side of the bucket, so as to catch in a ratchet fastened 
to the same side of the leg-piece. This arrangement places the com- 
mand of the movements of the knee-joint under the control of the 
person wearing the artificial limb, and enables him, when seated, to flex 
it, so that the pin will not inconvenience or trip persons moving 
around him, as it would do if it were straight and stuck out in front. 

The two preceding limbs are simple in their construction, and within 
the reach of the poorer classes, who are debarred from the use of the 
legs now to be described in consequence of their high price. The best 
of these, and the one we shall describe first, is that of Dr. Bly, of 
Eochester, N. Y., who has succeeded in producing a mechanism the 
movement of which imitates very closely those of the natural limb. 
It is adapted to an amputation above or below the knee, and it is par- 
ticularly where this joint is preserved and enjoys its normal motion 
that Bly's limb possesses a point of superior merit in external form. 
The artificial limbs for stumps below the knee, made formerly, were 
attached to the wearer's person by two straight lateral steel straps, 
jointed at this articulation; the angles formed by these metallic joints 
must project when the limb is bent at right angles, and raise the per- 
son's clothes in such a manner as to give the part an unnatural, bulky, 
and square appearance, at variance with the normal symmetry of the leg. 
Dr. Bly has overcome this objectionable feature perfectly by curving 
both the leg and thigh-straps in such a manner as to throw their point 
of junction further to the rear, on a level with the centre of the knee- 
joint, so that the clothes remain smooth when the knee is bent in 
assuming a sitting posture. 

This natural symmetry of the knee-joint is in accord with, and har- 
monizes with the perfection of form conferred upon the other portions 
of the limb, which, to bring it still closer in appearance to nature, is 
covered with a flesh-colored enamel, permitting a free use of water 
for cleansing and refreshing its surface. 

Besides these details of external form, the far more important ques- 
tions of the mechanical construction and motive powers of the joints 
have developed the ingenuity of Dr. Bly, and prove how indispensable 
a competent knowledge of Anatomy and Physiology is, to enable a 
person to design and prepare any apparatus in the treatment of the 
diseases and deficiencies of the human body. As we have seen, the 
leg is carried forward by gravity, when the foot is raised from the 



2-16 APPARATUS FOR REMEDYING THE LOSS OP PARTS. 

ground, and the hip corresponding to it swings forwards in an arc 
with its centre at the acetabulum of the opposite side, so that in 
reality there is no need of any motive power being placed in the knee- 
joint; yet in the construction of the artificial limb under consideration, 
some provision of this kind is made. A spring of railroad-car spring 
India-rubber is introduced, which, by its expansion after being com- 
pressed by flexing the leg, urges the latter forwards in taking a step ; and 
when the foot comes to the ground, in order to prevent shock, or any 
irregular action of the knee-joint, two cords are arranged to check its 
movements in imitation of the crucial ligaments in the natural articu- 
lation. The bucket, or thigh-sheath, articulates with the leg with the 
usual steel bolt ; indeed the bolts are the only iron used at all in any 
part of the construction of the limb, which confers upon it the im- 
portant quality of lightness, and a superiority in this respect over 
those mechanisms in which that metal enters. The friction of these 
metallic joints implies more or less wearing of iron, and must, there- 
fore, necessarily become loose, and unless repaired by bushing, rattle at 
every step; they also demand the free use of the oil-can to destroy their 
unpleasant and annoying clatter. In the ankle-joint the case is dif- 
. ferent ; there nature provides a number of muscles and a joint of 
peculiar construction for sustaining the leg in that line with the foot 
required by the gravity of the body, and for accomplishing the action of 
progression. It is in this respect and the form of the ankle-joint that 
the Bly leg possesses undeniable superiority over all others, if close 
imitation of the arrangements and functions of the natural limb will 
entitle it to a superiority. The ankle-joint naturally possesses four 
motions, flexion, extension, abduction, and adduction, which, readily 
passing from one to another, confer a compound motion equivalent to 
circumduction, enjoyed alone by the enarthrodial or ball-and-socket 
joints. The indispensableness, too, of this sort of compound motion in 
the ankle, for quick and easy progression, is seen when we observe a 
person walking gracefully and rapidly: the toes naturally turn out- 
wards, and the foot performs a sort of oblique antero- posterior move- 
ment, which could not be accomplished with a ginglymoid joint, a form 
of articulation adopted in most artificial limbs, except that of Dr. 
Bly. He employs a ball-and-socket joint for the ankle, the ball being 
of ivory and the socket of vulcanite, so that all the motions observed 
in the natural foot may be effected by the foot of his artificial limb. 
Further, the joint does not wear, nor require oiling, or bushing to keep 
it tight, but may be used for years unceasingly, without requiring the 
outlay of any more money than the original cost of the limb. The 
foot will remain flat upon the ground, should the leg be thrown out to 
brace the body for any unusual exertion or effort; and in walking 
upon the side of a hill, or any other inclined or uneven surface, the 
sole of the foot will assume a natural position, parallel with the plane 
upon which it rests. 

In the ginglymoid ankle-joint of other artificial limbs, this oblique 
action of the foot in locomotion can only be imitated by rolling it 
laterally ; and when the person wearing a leg constructed with such a 
joint walks upon an inclined or uneven surface, the side of the foot 



APPARATUS FOR THE LOWER EXTREMITIES. 



217 



alone remains in contact with it, while the upper edge of the bucket 
must be in consequence thrown forcibly against the thigh, much to 
his discomfort, and the impairment of firmness of step. 

The foot in Ely's leg is under the control of five catgut cords, con- 
nected with an equal number of India-rubber springs; these being 
placed beneath movable nuts, connected with the cords, traction of 
the latter compresses the India-rubber, and its expansion exerts the 
moving power of the foot. By adjusting the nuts, any desirable 
tension may be given to the cords to suit the person's gait. 

The toe-joint is also furnished with an India-rubber spring and 
catgut cord. 

The readiest way of understanding the foregoing description of 
this artificial limb is to examine attentively the annexed illustration. 
Fig. 160 shows a section of a limb for 
amputation above the knee. T is the bucket Fig- 160. 

with the piece D spanning the diameter of 
its lower part, and to which a cord and 
spring are affixed, ascending from the pos- 
terior part of the leg and serving the pur- 
pose of urging the leg forwards after it has 
been bent in taking a step. L is the leg- 
piece articulating at the knee with the 
bucket T, and having a diaphragm across 
its middle part through which the catgut 
cord c passes to be secured by the movable 
nuts N, between which and the diaphragm the 
springs s of railroad-car spring India-rubber 
are placed. There are but three of the five 
gut cords shown in the figure. B is the 
polished ivory ball working in a concavity 
lined with vulcanite. In the posterior half 
of the foot are seen the lower attachments 
of the gut cords, imitating the natural ten- 
dons. In the forepart of the foot, A F, the 
toe-spring is shown. Fig. 160, 2, shows the 
position the foot assumes when it treads 
upon a projecting object. 

Mr. Kolbe, of Philadelphia, has devised 
a leg in some respects superior to that of 
Bly. It possesses slight lateral motion of 
the ankle, enough to relieve the strain upon 
the thigh-sheath when the person steps upon 
an irregular or an inclined surface, while at Biy's artificial i<^ 

the same time it does not render the walk- 
ing unstable, as it must do if too great an amount of motion is given 
to the ankle. 

The external finish and strength of the limb give it rank with the 
best automatic appliance now offered for the patronage of the maimed, 
and one great recommendation it possesses is, that it may be adapted 
to every form or length of stump. 




248 APPARATUS FOR REMEDYING THE LOSS OF PARTS 



Fig. 161. 




Its mechanism is so simple that the wearer of the limb can in 
general be his own repairer should any portion of it give out or need 

overhauling, and this is no small advantage 
to persons residing at a distance from the 
manufacturer. 

The annexed cut (Fig. 161) shows a verti- 
cal section of a limb designed for an ampu- 
tation of the thigh. As is usual, the frame- 
work is of willow wood, which is selected 
for its tenacity, strength, fine grain, and light- 
ness. The thigh-piece or hucket is commonly 
lined with washed leather, fitting the thigh 
accurately and extending up to the ischium 
and perineum, which sustain a part of the 
weight of the body; the balance being dif- 
fused over the outer surface of the thigh. 
Its walls are opened by oblong slits or 
fenestra^ which permit the proper amount 
of ventilation being effected, and, at the same 
time, allow the secretions of the part to escape. 
The thigh-piece is strongly articulated at 
the knee to the leg-piece by a steel bolt, 
which permits antero-posterior motion only. 
From the inner surface of the lower third of 
the bucket a wooden pin, I K, projects, to 
which are attached two strong cords made of 
One of these, I E, being inserted into the heel, 
represents the tendo-Achillis ; it supports the weight of the body by 
preventing the foot being bent at any greater angle than a right angle. 
The other cord, K D, is inserted into the middle of the posterior sur- 
face of the leg, and is accessory to the former, 
an arrangement by which the limb is rendered 
so exceedingly strong that the weight of tfie 
strongest man cannot impair its stability. The 
cord marked G G is a spiral spring which is 
intended to give the leg a slight impulse for- 
wards in taking a step ; it is the analogue of 
the extension quadriceps of the natural limb. 
It has already been stated that this is useless, 
and experience proves it, in that most persons 
after becoming somewhat familiar with the 
motions of the leg throw this elastic strap 
aside. 

Fig. 162 shows the mechanism of the ankle- 
joint. It is somewhat peculiar, combining all 
the strength of a ginglymoid joint with lateral 
motion. The inferior surface of the leg and 
the corresponding surface of the foot are pro- 
vided each with a hemispherical depression which, when conjoined, 
form a hollow sphere; in the interior of this sphere the globular en- 



Kolbe's artificial leg. 



twisted linen thread. 



Fig. 162. 




Mechanism for lateral motion. 



APPARATUS FOR THE LOWER EXTREMITIES. 249 

largement seated at the centre of the steel ankle bolt works, the extre- 
mities of the bolt passing through the lateral metal straps in holes a 
little larger than their diameter ; these extremities are sustained by 
two pieces of India-rubber, which permit that amount of lateral motion 
desirable in the ankle. 

F F, in Fig, 161, indicate the position of a cord attached to a hori- 
zontal metallic spring fastened to the sole of the foot and intended to 
bring the foot again to a rectangular position with the leg after it has 
been extended : it is the analogue of the tibialis anticus. 

H A mark the metatarsal phalangeal joint; it is a simple tenon and 
mortise joint firmly bolted together, and under the control of a metallic 
spring which brings the toes straight with the foot after they have 
been extended by the weight of the body. 

Another automatic appliance of American invention is the Palmer 
leg. It is perhaps the best of the old style of artificial limb, and has 
hitherto enjoyed the approbation of the profession generally for its 
lightness, the ingenuity displayed in its construction and finish, and 
for that essential desideratum, efficiency. Mr. Palmer describes his 
invention in a pamphlet published by him in the following manner : — 

" The articulation of knee, ankle, and toes consists of detached ball 
and socket joints. The knee and ankle are articulated by means of 
the steel bolts, combining with plates of steel firmly riveted to the 
sides of the leg. To these side plates are immovably fastened the 
steel bolts. The bolts take bearings in solid wood (properly bushed) 
across the entire diameter of the knee and ankle, being stronger, more 
reliable and durable than those of the usual construction. All the 
joints are so constructed that no two pieces of metal move against 
each other in the entire limb. The contact of all broad surfaces is 
avoided where motion is required, and thus friction is reduced to the 
lowest degree possible. These joints often perform for many months 
without need of oil or any attention — a desideratum fully appreciated 
by the wearer. 

" The tendo-Achillis, or heel tendon, perfectly imitates the natural 
one. It is attached to the bridge in the thigh, and passing down on 
the back-side of the knee-bolt, is firmly fastened to the heel. It acts 
through the knee-bolt on a centre, when the weight is on the leg, im- 
parting security and firmness to the knee and ankle-joints, thus obvi- 
ating all necessity for knee catches. When the knee bends in taking 
a step, this tendon vibrates from the knee-bolt to the backside of the 
thigh. Another cord descends through the leg so as to allow the foot 
to rise above all obstructions, in flexion, and carries the foot down 
again, in extension of the leg for the next step, so as to take a firm 
support on the ball of the foot. Nature-like elasticity is thus attained, 
and all thumping sounds are avoided. 

" Another tendon of great strength and slight elasticity arrests the 
motion of the knee gently in walking, thus preventing all disagree- 
able sound and jarring sensation, and giving requisite elasticity to the 
knee. 

"A spring, lever, and tendon, combining with the knee-bolt, give 



250 APPARATUS FOR REMEDYING LOSS OF FUNCTION 

instant extension to the leg when it has been semi-flexed to take a 
step, and admit of perfect flexion in sitting. 

" A spring and tendons in the foot impart proper and reliable action 
to the ankle-joint and toes. The sole of the foot is made soft, to in- 
sure lightness and elasticity of step. 

" The stump receives no weight on the end, and is well covered and 
protected to avoid friction and excoriation." 

The Anglesea leg is generally adopted in England ; it is so named 
after the Marquis of Anglesea, who exhibited a lively interest in the per- 
fection of the limb, and used one himself. Like the Palmer leg, it con- 
sists of a wooden frame, imitating in shape the natural leg, and having 
the ordinary mortise and tenon joints, with iron bolts through their 
centres at the knee and ankle and moved by a catgut cord, re- 
presenting the flexor muscles of the leg and extensors of the foot, 
extending from the heel to the knee ; a strip of India-rubber is arranged 
in the forepart of the instep between the sole of the foot and the middle 
of the calf of the leg, for the purpose of flexing the foot. The action 
of the cord is to extend the foot when the leg is straightened, while in 
the bent position, just previous to making a step, it being relaxed, the 
elasticity of the instep band raises the toes from the ground, but not 
in such a manner or to such an extent as to give the heel a chance to 
touch the ground first when the foot takes its position in advance of 
the person, as is observed in the natural gait. The toes touch first, 
and the weight of the body brings the heel down with a shock. 

This construction also requires the leg to be made shorter than the 
natural one, in order to prevent the persons tripping at every step 
over the "slightest inequality of the surface upon which he may be 
walking. 

Not possessing the lateral movements of the ankle, as in the Bly 
and Kolbe legs, it is open to the objection of pressing painfully upon 
the thigh, and impairing the stability of stepping whenever one side 
only of the foot rests upon an oblique or irregular surface. 

In France and Germany elegant artificial limbs are manufactured 
after the models of Ferd. Martin, Mille, Charriere, Bechard, and 
Mathieu. 



CHAPTER II. 

APPARATUS FOR REMEDYING LOSS OF FUNCTION OF PARTS 

OF THE BODY. 

The loss of function of parts now to be considered affects principally 
the muscles and their tendons and the ligamentous structures connect- 
ing the different elements, or opposing articular surfaces entering into 
the composition of the joints. In their normal condition the muscles 
and tendons exert themselves uniformly and harmoniously in main- 
taining due balance in the execution of the respective offices of the 



OF PARTS OF THE BODY. 251 

various portions of the human frame with which they are in connec- 
tion, and retain in their position those organs inclosed by them. 

That the tendons participate in the production of certain deformities 
and other pathological states, as well as the muscles with which they 
are continuous, would seem to be proven by the observations of M. 
Jules Guerin, who dissents from the doctrine taught by Bichat and 
succeeding anatomists, that tendons are the passive instruments for 
the transmission of motion originated by the muscles, and have no 
contractility. Their contractility, it is true, cannot be excited like 
that of muscles by galvanism, resembling in this particular the dartos 
and some other contractile structures, yet that it does occur in certain 
pathological states, such as the deviation and deformities in the joints 
following some of the gouty, rheumatic, and scrofulous inflammations 
seated about the tendons, would seem to be established by accurate 
observation of those classes of disease. 

M. Guerin asserts also that he has demonstrated that, under a deter- 
minate condition, such as constant and excessive tension, a muscle 
may be converted into a fibrous condition, resembling in every histo- 
logical particular its tendon, of which it now forms but a mere pro- 
longation. Further, he had observed that muscles evidently in a 
fibrous state prior to section, the result of which was the restoration 
of their normal length and tension, frequently, in the course of years, 
or even of months, regain their fleshy condition. This latter observa- 
tion has an important bearing upon the mechanical treatment of the 
loss of function of these organs, inasmuch as it shows that though 
their fibres may be deeply involved in organic change, atrophy, and 
conversion to a fibrous state, the persevering use of appropriate mea- 
sures may, after the lapse of months, restore them to something of their 
pristine vigor and healthfulness. 

Deformities often result when one set of muscles lose the habitual 
and normal antagonism constantly exerted by an opposite set in con- 
sequence of their being paralyzed, or subject to some organic altera- 
tion ; or a muscle may overcome, by exaggerated action, its antagonist 
acting normally. 

As a general rule, the abnormities of function of parts of the body 
are more remediable by mechanical appliances when the unequal 
action of the muscles result from local causes than when it occurs in 
consequence of some permanent or long-continued morbid alteration 
of the system at large, as of the nervous centres. Hence, the para- 
lysis of the limbs from centric causes is in general but little alle- 
viated by the use of any apparatus ; while in other instances, in which 
local changes are the sources of altered function, much benefit is 
almost always derived from proper treatment, and cures are not un- 
frequently obtained. 

Besides these causes — changes in the muscles themselves, and cen- 
tric or excentric paralysis — of loss and impairment of function of the 
muscles, a peculiar sort of paralysis is sometimes observed in hysteri- 
cal persons, which is simply the result of exalted nervous action, and 
implies no local change in the muscles further than may result from 
the long-continued inaction during this state, nor permanent change in 



252 APPARATUS FOR REMEDYING LOSS OF FUNCTION 

the nerve-centres. Such cases are frequently cured as soon as the 
condition upon which they depend is removed, whilst any lingering 
impairment of the tone of the muscles, after successful general treat- 
ment for the hysteria, may be advantageously met with exercise, local- 
ized movements of the affected muscles, and appropriate apparatus. 

As most of the diseases falling under the present head are chronic, 
they require chronic treatment ; an overweening confidence in appa- 
ratus of any description for a speedy cure will surely be disap- 
pointed. The patient must exert himself to obtain full control over 
the affected muscles by a vigorous exercise of his will, to develop any 
remaining muscular power while the surgeon endeavors to supple- 
ment it with properly arranged mechanical forces to overcome the 
stronger action of opposing muscles, and at the same time employs 
frictions of the parts with stimulating applications for the purpose of 
exciting the capillary circulation and rousing the dormant nutritive 
activity. The mechanical manipulations should be employed for a 
short time only at first, and the periods gradually lengthened as the 
restoration of function progresses, observing regularity, the patient 
bearing in mind always that no good results can be accomplished by 
fitful and irregular treatment; one, perhaps, carefully observed for a 
few days and then dropped for a week, or some indefinite period, to 
be again resumed at the suggestion of his caprice. 

SECTION I. 

APPARATUS FOR REMEDYING LOSS OF FUNCTION OF THE MUSCLES OF THE 

HEAD AND NECK. 

Loss of Function of the Cervical Muscles. — It occasionally 
happens that the extensor muscles of the head, in consequence of para- 
lysis, are unable to maintain it in an erect position, and in conse- 
quence the head falls forward towards the chest, the chin reposing 
upon the upper part of the sternum. The same result may also occur 
from the active and permanent contraction of the flexors of the head, 
the erectors opposing little if any resistance to their action in causing 
the displacement. 

The course of treatment to be pursued should have especial refer- 
ence to the improvement of the general health by tonics and appro- 
priate exercise, aiding the restoration of the power of the muscles 
affected by systematic localized movements. It is important to dis- 
criminate this affection from that in which the forward inclination of 
the head depends upon disease of the substance of the vertebrae 
themselves. 

To maintain the head erect, if no resistance is offered by the flexor 
muscles, two curved padded stems, projecting upon either side of the 
neck from the upper extremity of a long metallic lever running along 
the spine, may be placed beneath the chin; the head being rendered 
more steady by a circular strap passing around the forehead. The 
stems move laterally in opposite directions, and by means of a ratchet 
screw, controlled by a key at their junction with the vertebral lever, 
may be elevated or depressed at pleasure ; the lever itself takes its 



OF MUSCLES OF THE TRUNK. 253 

support upon the pelvis by two straps passing around the body ; 
and opposite the axilla two curved supports project from it beneath 
the shoulders. 

A still more convenient apparatus is formed by attaching to the 
upper end of the vertebral lever two arms padded at their extremi- 
ties to grasp the sides of the head, and capable of being separated 
laterally and moved upwards and downwards by ratchet-centres. 

Should the muscles involved in the paralysis permit the head to 
fall sideways upon the shoulder, either of the above instruments, with 
the addition of a lateral centre of motion to the vertebral lever in the 
neighborhood of the seventh cervical vertebra, will suffice to sustain 
the head erect, while the constitutional treatment appropriate to the dis- 
eased condition upon which the paralysis depends, is being carried out. 

SECTION II. 

APPARATUS FOR REMEDYING LOSS OF FUNCTION OF MUSCLES OF THE 

TRUNK. 

Apparatus for Remedying Loss of Function of the Erector 
Muscles of the Spine. — In the natural condition of the muscles and 
ligaments connected with the spine, that column is maintained with 
the greatest facility in the erect position without fatigue or exertion. 
For this purpose the large and powerful muscles lying in the verte- 
bral grooves, with numerous connections with the bodies and pro- 
cesses of the vertebras, are admirably adapted. The varied move- 
ments of the body involve more or less disturbance in the equilibrium 
of the spine, which is promptly restored by the energy of the muscles 
as soon as the disturbing influences are removed. 

Certain departures from this normal action of the vertebral muscles 
and ligaments are sometimes observed, and are designated usually 
" spinal debility." In its mildest form it consists in a simple debility 
of these tissues, the muscular fibres losing tone, and partaking in the 
constitutional weakness, always present in such cases, of the other 
voluntary muscles. The spine is disposed to deflect laterally from 
the median line without any changes in the organic integrity of the 
bones themselves, though this condition, if permitted to exist for a 
sufficiently long period, will induce such changes and also permanent 
curvature. 

The disease is observed in young persons between the ages of five 
and fifteen, of a weakly habit of body, and growing rapidly. In these 
cases* the general health will be found to be more or less impaired, 
the digestive and assimilating functions deranged, and the secretions 
morbid. These individuals furnish many of the instances of permanent 
curvature that present themselves at a later period of life. Parents 
frequently neglect the physical education of their children in their 
anxiety to develop their mental powers; and the result under the 
system pursued at the present time in our schools is that any spinal 
debility that may exist is aggravated by the confinement in the 
school-room into positive deformity, and such a condition of things 
is established that months of patient mechanical treatment will be 



254 APPAEATUS FOR REMEDYING LOSS OF FUNCTION 

required to remove curvatures in cases where continuous and early 
recourse to fresli air, exercise, and a proper diet would have sufficed 
to restore health and vigor to the system. 

From what has been said above, it may be gathered that in case of 
spinal debility it is of prime importance to attend to the general 
health, to restore the tone of the muscles by open-air exercise and 
gymnastics, to improve the digestive and assimilating functions by 
tonics — iron, quinia, cod-liver oil, cold bathing, &c. Direct the children 
to abstain from bending the spine laterally over desks in studying and 
writing, or indeed assuming any fixed posture continuously. 

While the constitutional treatment is being conducted upon the 

above principles, some mechanical support of the spine may be had 

recourse to. A simple apparatus for this purpose 

Fi S- 163 - is the one depicted in Fig. 163, consisting of two 

jf\ vertical metallic levers, one upon either side of 

^^^^ m j the spine, connected above with a pad fitting the 

■ ^\J|g|L back between the scapulas, and taking their point 

^^^^^^^^^ °f support upon a padded pelvic strap firmly 

^^^^^Ifgj^ secured around the hips. From the upper ex- 

r~HM!f» Hnr tremities of the levers two axillary supports pro- 

\ ill! IlilB fPw J ect beneath tne shoulders, each bearing a strap 

r'llllillilll 1^ at tne ^ r P°i nt s, and intended to pass over the 

|_jL^ clavicle and scapula, to be buckled to the vertical 

^j^Sllli^^JL. stems. To confer additional steadiness upon the 

'^^^^IpO^ apparatus, a laced abdominal band is connected 

#^ ^^j|^3fp^S^ with the levers, and another one extends between 

^^^^0^^ the pelvic straps across the hypogastrium. 

Dr. Abbe, of Boston, devised an apparatus to 
support the spine. It is a wire-gauze frame accurately moulded to 
the posterior portion of the back, and bound by stout wire. The 
frame is open at the loins, where a short vertebral jointed stem con- 
nects the dorsal and pelvic pieces together; the stem is supported 
erect by two lateral bands of India-rubber, acting in opposite direc- 
tions. The apparatus takes its point d'appui upon the pelvis, and is 
secured to the body by two broad bands, one encircling the chest and 
the other the abdomen, lacing in front, and by two shoulder-straps. 
The frame is light, exercises uniform pressure, and permits the insen- 
sible perspiration to escape freely. 

Loss of Functions of the Muscles of the Abdomen. Hernial 
Bandages. — The abdominal cavity, unlike those of the cranium and 
chest, is bounded by yielding walls composed of muscular and ten- 
dinous structures, and is pierced at points with certain apertures to 
give egress and ingress to vessels, nerves, and ducts. It is constantly 
undergoing changes of dimension by their contraction, by which the 
viscera are subject to a varying degree of compression at all times : 
during active exertion, particularly, the force is much increased ; and 
should morbid changes or congenital defects have produced alteration 
in these apertures, the viscera, compressed from every direction, are 
at this time liable to escape from the abdomen through the orifices, 
and appear externally under the form of a tumor. The sudden manner 



OF MUSCLES OF THE TRUNK. 255 

in which this usually takes place gives the impression and semblance 
of a veritable breaking through or rupturing of the walls, and hence 
the injury was long ago and is now popularly known as rupture; the 
more scientific designation, hernia, being derived from the Greek 
word Ipvoj, a young sprout. 

Hernia is distinguished into certain species, according to the locality 
in which the tumor is located: if at the external orifice of the inguinal 
canal, it is called inguinal; crural, if at the orifice of the crural canal; 
and umbilical, when the rupture occurs at the navel. These are the 
chief varieties of hernia, although there are certain rarer forms, the 
occurrence of which should be known, caused by the viscera appearing 
at other points than those above mentioned. They are ventral, the 
tumor being formed over any accidental or natural deficiency in the 
tendon of the external oblique muscle ; obturator, the bowel escaping 
through the aperture in the upper margin of the obturator or thyroid 
membrane; ischiatic, in which the bowel protrudes at the ischiatic 
notch beneath the gluteal muscles; perineal, the tumor being formed 
in the perineum by the intestine making its way between the bladder 
and rectum ; vaginal, produced by the yielding of the wall of the 
vagina ; and 'pudendal, the bowel following the course of the round 
ligament until it gains the labium major, between its cuticular and 
mucous laj^ers. 

The mechanical contrivance by which this abnormal displacement 
of the abdominal viscera is sought to be corrected, and, under certain 
circumstances, cured, is called a hernial bandage, or truss. The general 
form of a truss is an elastic steel spring covered with buckskin, bearing 
at its anterior extremity a small pad to make pressure upon the her- 
nial opening, and at the other a larger pad to secure a counter-pressure 
upon the loins; perineal straps are connected with the pad and spring, 
to prevent the instrument being displaced during the movements of 
the person wearing it. The oldest form of a hernial bandage was 
simply a padded pelvic strap with a large pad, the introduction of the 
steel spring, in 1781, being due to Mathias Major, since which time 
both the metallic spring and the pad have undergone innumerable 
modifications, according to the peculiar mechanical views of surgeons 
or of manufacturers of the bandages. The pad has sometimes been 
recommended to be made small and oval, at others large and round; 
now pyriform, and again triangular. The materials of which it is 
composed have been equally varied : in some trusses it is composed 
wholly of metal, ivory, or glass ; in others, of soft leather stuffed with 
horse-hair, floss-silk, fine white sand, or other like materials. 

An important feature in the construction of a truss is the manner 
of attachment of the pad with the spring, In the older instruments 
above mentioned this was effected by a solid joint which permitted no 
motion of these parts upon each other, and therefore the person in 
moving about and constantly altering his attitude caused the pad to 
slip from over the hernial opening. The way of avoiding this incon- 
venience is to connect the pad and spring together by a movable joint, 
several varieties of which have been adopted, as will be seen in the 
description of the instruments figured below. 



256 APPARATUS FOR REMEDYING LOSS OF FUNCTION 




Single inguinal truss. 



The form of the truss must also vary in shape according to the 
variety of hernia in which it is intended to be employed. 

1. In inguinal hernia, a truss (Fig. 164) commonly employed in 
this country, but nevertheless of little merit, consists of a metallic 

spring immovably attached to its pad and 
intended to span almost the whole circum- 
ference of the pelvis, the interval being made 
up by a strap perforated with holes to receive 
a short tenon placed upon the plate of the pad ; 
the pad is oval, convex, and of unequal thick- 
ness, the broader margins being at its farther 
extremity, which rests upon the internal 
pillar of the abdominal ring, and at its lower border, which should 
press upon the spine of the pubis to prevent the bowel slipping be- 
tween it and the pad. This kind of spring and pad is selected that it 
may control the protruding viscera by pressing upwards, backwards, 
and a little outwards in the direction of the inguinal canal, which is 
exactly the reverse direction taken by the intestine in descending to 
form a tumor exteriorly. 

This instrument is applied upon the side opposite that upon which 
the hernia is seated. 

As there may be two or even three ruptures in the same subject, an 
additional pad has occasionally been attached to this instrument ; but 
the arrangement is a very bad one, as it produces unequal pressure 
and is otherwise very insecure. 

The improvement upon this is to place the two small pads at the 
extremities of the metallic spring, in double inguinal hernia, for ex- 
ample, and a large pad in its centre to make the counter-pressure over 
the lumbar region. 



Fig. 165. 



Fig. 166. 





Salmon and Ody's single truss. 



Salmon and Ody's double truss. 



The objections to the immovable pad already stated were so evident 
as to lead to numerous attempts to obviate them ; and the efforts were 



OF MUSCLES OF THE TRUXK. 



257 



crowned with more or less success. Salmon and Ody introduced a 
truss (Fig. 165) which has been in high favor for years, and is now 
extensively employed. It consists of a spring spanniug half the 
body from the spine to the abdominal ring upon the sound side. 
The pad is oval, and attached to the spring by a ball and socket joint, 
so that it participates in all the motions of the body, and therefore is 
not easily displaced. In double inguinal hernia, two pads are fastened 
in the same manner to the spring which takes its point of support by 
a broad pad upon the spine. (Fig. 166.) 

Coles' truss differs from that of Salmon and Ody's, in that the spring 
extends from the spine to the inguinal ring on that side upon which 
the hernia is seated ; and instead of the ball and socket joint, the pad, 
which is long and pyriform, is enabled to participate in the movements 
of the body by means of a flat spiral spring attached to its anterior 
surface. 

Dr. Todd suggested a modification of the spring (Fig. 167) in order 
to obtain a more energetic pressure upwards and backwards, so that 
instead of passing around the pelvis as in the two former instruments 
it mounted over the crest of the ilium and terminated in a small oval 
pad. 

Wickham has introduced a ratchet-wheel into the composition of 
the pad, so that by means of a screw the pressure may be increased 
or diminished at pleasure. 

To obtain the same result Dr. Arnott had previously proposed that 
a chain be attached to the spring along its length capable of being 
controlled by a key. 



Fig. 167. 



Fig. 1 





Todd's truss. 



Bigg's truss. 



In certain obstinate cases of inguinal rupture, Mr. Bigg, of Loudon, 
has succeeded in retaining the bowel reduced, by means ot* a triple- 
lever truss (Fig. 168) which exercises force in three different lines. 
He explains this kind of an apparatus in the following manner: " A, 
B, C are three springs of different lengths, moving freely by means 
17 



258 APPARATUS FOR REMEDYING LOSS OF FUNCTION 

of small staples on the margin of a triangular pad. D is a soft padded 
leather or silk band passing around the pelvis and containing within 
it the three springs. E is a silk strap fixed to the lower spring. A, 
a small button placed in the centre of the pad acts upon the springs, 
and on being turned increases or diminishes the pressure upon the 
hernial ring. Owing to the various lengths and positions of the 
springs each acts in a different direction upon the rupture. A tilts 
the lower edge of the pad upwards ; B acts equally upon the whole 
surface of the pad, pressing it inwards and upwards ; while C acts upon 
the centre of the pad, forcing it directly inwards. By the combined 
action of the three springs the tendency of a severe rupture to slip 
beneath the pad is effectually controlled. 

In the truss of Stagner and Hood, improved by Chase and others, 
the pad is made of birch or cedar, a material possessing lightness and 
at the same time sufficient closeness of texture as not to absorb the 
secretions of the part to which it is applied, or to wear out ; it is oval 
in shape and convex upon its ventral surface ; and articulated witb 
the spring by a joint which permits the angle formed by it with the 
spring to be varied at pleasure so as to secure the most perfect adapta- 
tion to the surface. The spring is constructed in the usual manner and 
spans two-thirds of the body, its extremities being joined by a leather 
strap perforated with holes to be fastened to a button just beyond the 
pad ; the counter-pressure is made by a round pad upon the back part 
of the spring. When the apparatus is applied in order to prevent its 
slipping up over the hips, a thigh-strap is attached. 

The best truss I am acquainted with, for the treatment of inguinal 
hernia, is the one seen in Fig. 169, manufactured by the surgical 

instrument makers of this city and sold 

Fig. 169. under the name of " Hood's truss." It 

is constructed of two simple trusses 

connected together by a curved spring 

spanning the space between the two 

anterior pads ; the posterior pads rest 

upon the fleshy masses upon either 

side of the spine, and are connected 

Hood's truss. by a leather strap. When properly 

applied it is almost impossible, by any 

movements of the body, to displace this instrument from the position 

assigned it upon the pelvis and groin. If the hernia is single, but one 

of the anterior oval plates is then padded, the other is simply covered 

with buckskin to prevent the skin being chafed; in double hernia, of 

course, both pads are used. 

Besides the metallic spring truss, there are those in which the elastic 
force of India-rubber is employed. M. Dupre's hernia bandage is of 
this description ; as it has been found of service in many cases, and is 
now frequently employed in France, a brief description of it may be 
acceptable. The frame of the instrument (Fig. 170) is formed of a 
stout wire, bent to adapt itself to the outlines of the pubis and inguinal 
regions, and supporting in front one or two pads, according as the 
hernia is single or double. To the extremities of the arc an elastic 




OF MUSCLES OF THE TRUNK. 259 

band, furnished with buckles to fasten behind, is attached, and by it 
the pressure of the pads is regulated at will. 

Fig. 170. 




Dupre's truss. 

A bandage composed entirely of elastic material has been occa- 
sionally recommended in the treatment of inguinal rupture. Strips 
of India-rubber are fastened together in a spiral manner, and their 
contraction maintains an elastic pad over the inguinal ring. In this 
manner, M. Bourgeand has devised an apparatus for preventing hernial 
extrusions, consisting of inflated India-rubber pads, which are confined 
over the abdominal rings and inguinal canals by a broad elastic band. 
It is intended to obviate the supposed atrophic effects of the pressure 
of the pad of the ordinary truss upon the cellular and muscular tissues 
of the groin, which thereby weakens the part, by substituting the 
gentle, uniform and effective pressure of an air pad. Another advan- 
tage claimed for the apparatus is that the abdomen is gently com- 
pressed by the elastic belt, and the intestines thereby effectually sup- 
ported in their normal site, so that there can be but little disposition 
on their part to protrusion. 

Experience has not confirmed the superiority of Bourgeand's con- 
trivance over the spring truss, and it is therefore now little used. I 
have employed a modification of it with advantage in the treatment 
of large irreducible hernias ; giving the air-pad a sufficient concavity 
to embrace the tumor. 

In the moc-main truss the elastic resistance of a spring is employed 
in the following manner : a padded belt surrounds the pelvis bearing 
a large oval pad stuffed with floss silk, and having attached to it a 
short metallic spring. The pad is kept pressed against the inguinal 
canal by a thigh strap fixed to the end of the spring. 

When the viscera have escaped from the abdomen and found their 
way into the scrotum, forming a moderate-sized tumor, considerable 
more difficulty will be encountered in keeping the inguinal canal and 
its rings closed than in simple cases of bubonocele, or where the tumor 
exists in the groin, and for which the trusses above described are 
especially adapted. 

The action of a truss for oscheocele or scrotal hernia should be to 
close the entire length of the passage followed by the escaping 
bowel. The best form of a bandage to effect this will be one with 
a large fusiform pad supported by a spring encircling the pelvis, 
and having its lower end firmly held in contact with the parts beneath 



260 APPARATUS FOR REMEDYING LOSS OF FUNCTION 



Fig. 171. 



"by a thigh-strap passing around the thigh opposite the side upon 
which the hernia exists, and Fastening above to the spring. The appli- 
cation of a truss with a large concave pad to an irreducible hernia may 
in time effect its reduction, but such instruments should be employed 
with prudence. In some of these instances of large scrotal hernias, 
irreducible in consequence of adhesions established with surrounding 
parts, the only mechanical contrivance either advisable or practicable 
is a simple suspensory bandage which will ameliorate the patient's 
condition, and enable him to pursue his avocations in life with com- 
parative comfort. 

2. Crural or femoral hernia. The truss (Fig. 171) employed in the 
treatment of this form of rupture possesses the 
same general features as that for inguinal hernia, 
viz : a metallic spring and pad ; but, from the 
fact that the crural ring is inferior and external 
to the external abdominal ring, the neck of a 
crural truss must be longer, and the pad must 
form a less oblique angle with the spring which 
should always span the diseased side. As the 
pad, which must be peculiarly shaped, reposes 
in the folds of the groin, it is apt to be displaced 
by the movements of the thigh, and therefore a 
thigh -strap becomes indispensable. 

3. Umbilical hernia is most frequently met 
with in infancy in consequence of a tardy closure 
of the umbilicus during development, and in 
adults principally among the corpulent. When 
the viscera have been restored to the abdominal 
cavity they are, in general, easily retained there 
by a properly constructed truss, a simple form 
of which for an infant, or in a mild case in the 
adult, may be prepared with gum elastic in the shape of a band three 
or four inches deep and lacing bejaind. In front, a pad, a little larger 
than the umbilical opening and slightly convex, is attached to the 
belt to restrain, by its pressure, the extrusion of the bowel. The size 
of the pad is an important point in the treatment of this disease ; if it 
is too small, the elastic band or metallic spring (if that is used) is apt 
to sink it into the opening, and thus defeat the very object that was 
had in view in employing it. 

Should the elastic force of the India-rubber not succeed in restrain- 
ing the issue of the viscera, then recourse must be had to a metallic 
spring encircling the body (Fig. 172) and attached to a compressive 
pad in front. An irreducible umbilical hernia may be benefited, and 
in time rendered reducible, by constructing the anterior pad with a 
concave ventral surface which is gradually to be diminished in pro- 
portion to the lessening size of the tumor under the pressure, until a 
convex pad may be employed. 

If no well-constructed pad is at hand, as those above mentioned, a 
simple leathern or elastic belt having an oval pad, or, better still, an 




Femoral truss. 



OF MUSCLES OF THE TRUNK. 261 

air pad, attached to its middle, will answer as a substitute for them, 
and will do good service. 

Fig. 172. 



Umbilical truss. 



4. Ventral hernia may be treated with the same instruments as those 
used in the umbilical form of rupture, modifying them, of course, to 
suit the necessities of individual cases. 

5. Obturator or thyroid hernia, occupying, as it does, a position 
beneath the ramus of the pubis, may be effectually kept reduced by a 
truss similar to one adapted for inguinal hernia, with the difference 
that its neck should be more elongated and the pad smaller, more 
convex, and oval. 

6. Ischiatic hernia is more difficult of management, but is yet capa- 
ble of being controlled by a truss formed of an elastic spring to 
encircle the pelvis, and an oval pad to rest on that part of the gluteal 
region corresponding with the ischiatic notch. 

7. Perineal hernia requires a truss of rather peculiar construction 
consisting of a padded pelvic strap, from the posterior and central 
part of which a curved metallic spring projects as far as the tumor, 
and bearing upon the extremity a firm oval pad to exercise com- 
pression upon the protrusion. 

8. Vaginal hernia can be most effectually treated by properly con- 
structed pessaries, an account of which will be found further on. 

9. Rectal hernia, resembling vaginal rupture in occurring in one of 
the natural canals of the body the walls of which form the sac con- 
taining the displaced intestine, like it, also requires pessaries, the 
proper form of which will be seen in a subsequent section. 

10. Pudendal hernia, formed by the bowel following the course of 
the round ligament in the inguinal canal, is the analogue of inguinal 
rupture in the male, and requires for its treatment the inguinal truss 
already described. 

Application of Trusses. — It is of the first importance to secure 
a properly made hernial bandage for each individual case under 
treatment, and for this purpose the surgeon should take the necessary 
measurements of the pelvis of the patient. This may be done with a 
simple tape measure, placing its extremity upon the hernial tumor 
and carrying the line horizontally around the pelvis upon the same 
side to the spine, and noting the number of inches, which will be the 



262 APPARATUS FOR REMEDYING LOSS OF FUNCTION 

length for the spring. A better way, however, if it is practicable, is to 
take the measure with a piece of wire, which will give at the same 
time the contour of the hip. A great deal of injury has been perpe- 
trated by the vendors of ready-made trusses, who sell their instruments 
indiscriminately without regard to the condition of the patient, or 
their adaptation to the parts to which they are to be applied : and thus 
a person, lulled to a sense of security by the fact of his having on a 
truss, without considering its efficiency, may become suddenly a victim 
to strangulation by indulging even in an ordinary degree of exertion ; 
a result that would not have taken place at all, had he attended to this 
point and secured a really good instrument. 

The surgeon having procured a properly fitting truss, proceeds to 
apply it by placing the patient in a horizontal position, and when the 
entire contents of the hernial sac have been returned into the abdo- 
men, he places the first two or three fingers of the left hand upon the 
ring and prevents their descent, while with the right hand the truss 
is unfolded and slipped around the pelvis, the compressing pad being 
gradually brought over the ring as the fingers are withdrawn. The 
straps are then to be secured immediately, and the patient directed to 
rise and move about, to cough, and change his position, while the 
surgeon makes sure that all is secure by a careful examination. But 
if the bowel should descend, the truss must be manipulated anew until 
a complete retention is secured. 

For the first few weeks, perhaps, the patient may feel a little annoy- 
ance from the truss ; this will speedily disappear if the spring is not 
too strong, a circumstance that may be known by the pad not leaving 
a depression in the part beneath it. The only amount of pressure, 
either required or advisable, is that just sufficient to prevent the intes- 
tine escaping from the abdomen : this important point is sometimes 
overlooked, and the result is, that with such stiff truss-springs as are 
often furnished, inflammatory swelling of the testicle and scrotum, vari- 
cocele, excoriation of the skin, and absorption of the tissues compressed, 
are some of the accidents liable to follow their use. The spermatic 
cord must also be carefully exempted from injurious pressure of the pad. 
The truss is essentially a palliative instrument in patients beyond the 
18th or 19th year ; but in children it is generally successful in oblite- 
rating the canal ; and, faithfully employed, will effect a cure in from 
twelve to eighteen months. In adults this result is rarely obtained, 
even after years of perseverance with the use of the truss : the only 
advantage accruing from its employment, though that is a very im- 
portant one, is the retention of the abdominal viscera in their natural 
cavity, and freedom from the chance of their becoming strangulated. 

The instrument must be worn constantly, day and night ; and it will 
be well, during any unusual exertion, violent coughing, sneezing, and 
the like, to support the pad with the fingers. During warm weather, 
to prevent excoriation, it will be advisable to interpose between the 
pad and the skin a fold of soft linen. Some persons are in the habit, 
occasionally, for the same purpose, of wearing the truss over an under- 
garment, a plan which cannot be too strongly condemned, for the rea- 



OF MUSCLES OF THE TKUNK. 263 

son that the pad is thereby constantly liable to be displaced, and to 
permit the bowel to escape. 

The Taxis. — The reduction of hernia by manipulation is techni- 
cally called taxis. As there are certain general rules to be observed 
in employing the taxis in the different kinds of hernia, a cursory 
allusion to them in this place will save further repetition when we 
come to consider each variety separately. 

Position. — The best position to place the patient in to obtain as 
perfect a relaxation of the muscles as possible, is the horizontal, 
with the hip elevated, and the thighs somewhat flexed. Some per- 
sons prefer to place the patient upon a sofa, with its end sloping 
upwards, over which his legs hang, while his head rests upon its centre, 
in a lower plane than the rest of the body. Although the position of 
the patient will contribute much towards relaxing the muscles, there 
are other adjuvants still more potent. 

Ansesthetics. — It was formerly the custom to produce muscular relax- 
ation by the warm bath, the administration of tartar emetic, injections 
of an infusion of tobacco, and copious venesection; but the discovery 
and introduction of the anaesthetics in surgery have well-nigh rendered 
the use of these agents obsolete, though under circumstances where 
chloroform or ether are not attainable, these means may be had 
recourse to, and will prove of service. It has, also, been recommended 
that cold be applied to the scrotum to contract and to condense the con- 
tents of the sac for facilitating their return. Powdered ice, wrapped 
up in a piece of oiled silk, or cold water, applied to the bottom of the 
tumor, will be as good a plan as any to obtain the physiological action 
of cold. 

In the application of compression, which requires the greatest dis- 
cretion as to its amount, duration, and direction, it must always be 
borne in mind that, although the taxis will often succeed in accom- 
plishing the reduction of the hernia, there are numerous cases in 
which it will fail, and herniotomy is required ; then the future wel- 
fare of the patient as to his chance of surviving will depend, to a 
great extent, upon the amount and character of the manipulation to 
which the intestine has been subject in the taxis. The amount of 
compression that may be prudent, without jeopardizing the subsequent 
well-being of the patient, should the taxis fail, and an operation be- 
come necessary, may be exercised by seizing the hernial tumor in the 
palm of the hand, and with the fingers, knead gently the part, until its 
contents give the sensation of uniformity, when gentle traction should 
be made upon it to draw down the intestine a little to disengage it 
from the ring. Then the pressure of the hand must be exercised 
upon the tumor at every part embraced, so that the upper portion of 
its contents alone may press upon the ring, while the fingers of the 
opposite hand are employed in pressing the intestine, little by little, 
through the ring in an appropriate direction. If the whole tumor is 
compressed directly against the ring its contents will spread out over 
it, and frustrate the surgeon's efforts. 

The duration of the compression should not be too long, as the case 
becomes more and more grave with the duration of the strangulation, 



26-i APPARATUS FOR REMEDYING LOSS OF FUNCTION 

and the chances of success of herniotomy diminish in a direct propor- 
tion. After the patient has been fully etherized, and taxis employed 
judiciously, for a period longer or shorter, according to the circum- 
stances of the case, and the reduction cannot be accomplished, another 
trial may be made in a few minutes, by changing the patient's posi- 
tion, or having recourse to another method of taxis than the one at 
first tried. Should this in like manner fail, the surgeon had better 
suspend his efforts, and subject the patient to herniotomy without 
delay. 

The direction of compression must vary in the different forms of 
hernia, and will, therefore, be considered further on. 

In applying the taxis it will be advisable to endeavor to ascertain 
the character of the contents of the hernial sac by a careful examina- 
tion, so that the parts may be reduced in the reverse order of their 
extrusion ; that is, intestine first, and then omentum. The constitu- 
ents of a hernial tumor may be defined to a certain extent by its phy- 
sical characters. The descent of the bowel containing gaseous mat- 
ter (enterocele) will produce a tumor more or less elastic, smooth, and 
uniform to the touch, and is usually larger, more sensitive, and more 
easily reduced than one containing omentum only, the reduction tak- 
ing place suddenly, and accompanied by a peculiar gurgling noise. 
The presence of omentum in the tumor (epiplocele) confers upon it an 
irregular, soft, and doughy feel ; and the reduction takes place slowly 
and without noise; it is usually smaller than an enterocele. When 
the hernial protrusion contains both intestine and omentum (entero- 
epiplocele) it will partake, in a measure, of the characteristics of both 
the preceding varieties, a part of it feeling elastic, while the other is 
doughy. 

1. taxis of Inguinal Hernia. — As already stated, inguinal hernia is 
formed by the intestine escaping at the external abdominal ring, and 
it is said to be indirect or external, when the bowel enters the internal 
abdominal ring and courses the inguinal canal, and direct or internal 
when it escapes by forcing before it the conjoined tendon of the inter- 
nal oblique and transversal is muscles. In the former case the direction 
will be downwards, inwards, and forwards, and in the latter forwards 
and downwards. The terms internal and external inguinal hernia 
refer to the position of the neck of the sac, as regards the epigastric 
artery. If the protruding viscera are arrested in the groin, the her- 
nia receives the name of bubonocele, while it is designated oscheocele 
when they are contained in the scrotum. 

In using the taxis in inguinal rupture, the patient should be placed 
in the position indicated above, to relax the abdominal muscles as 
thoroughly as practicable, and then be completely anaesthetized. The 
surgeon takes his position upon the side of the patient upon which 
the hernia is, grasps the tumor in the palm of one of his hands and 
compresses it to diminish its bulk, while with the fingers of the other 
hand placed over the external abdominal ring, he endeavors to press 
the contents of the upper part of the tumor into the abdomen, little 
by little, until the whole of the displaced viscera shall have been 
restored to their natural cavity. The pressure must be exercised in 



OF MUSCLES OF THE TRUNK. 265 

indirect hernia upwards, a little backwards and outwards; while in 
the direct variety the line of pressure ought to be upwards and back- 
wards. In long-standing cases of indirect rupture, the two rings are 
drawn more or less into the same line, so that the manipulation in these 
cases will have to be modified, so that the pressure may bear upwards 
and almost backwards, as in direct hernia. Generally, as soon as the 
constricted portion of the intestine is replaced, the remainder will 
slip in immediately. 

A plan for the taxis, as recommended by M. Despres, in small in- 
guinal hernia, is thus described by Jamain: The surgeon applies the 
cubital border of the left hand a little above the pedicle (or neck) of the 
hernia, strokes it in such a manner as to draw the tumor into the scrotum ; 
then compresses the tumor with the right hand more or less firmly, 
according to the volume of the hernia ; and the hernia enters, after 
some efforts, of which the surgeon regulates the intensity and duration. 

This is the way M. Despres explains the mechanism of this process: 
1. He fixes the neck of the sac, the principal obstacle to the reduc- 
tion. 2. In pressing upon the tumor he diminishes the volume of the 
intestine at the orifice of the sac. 3. In pressing with the right hand 
he causes the intestinal loop to execute a movement analogous to that 
of two fingers opening a purse. 

Dr. Wise, of India, describes in the London Journal of Medicine 
the following way of making the taxis, which he states to have been 
followed by success : " Place the patient on a table, and having folded 
a Jong sheet several times on itself, carry it around the lower part of 
his pelvis, twisting it on itself, in front and again at the sides, so as 
to enable the assistants, who stand on each side to hold the extremi- 
ties of the sheet, and pull them gently upwards or towards the 
patient's head, while a third assistant holds the feet, and the surgeon 
makes the taxis. As the gut immediately above the strangulated 
portion is often superficial, and distended with flatus and liquid, it 
will be drawn upwards from the hernial sac, whilst the return of the 
protruded portion is favored by the taxis practised by the surgeon." 

I have succeeded in reducing two cases of strangulated inguinal 
hernia by a mode highly recommended by M. Seutin. It is effected 
in the following manner: "The patient is laid upon his back, with 
the pelvis raised much higher than the shoulders, in order that the 
intestinal mass may exert traction upon the herniated portion. The 
knees are flexed, and the body is slightly turned to the opposite side 
to that on which the hernia exists. The surgeon ascertains that the 
hernia, habitually reducible, cannot be returned by continuous and 
moderate taxis. He next seeks with his index finger for the aperture 
that has given issue to the hernia, pushing up the skin sufficiently 
from below in order not to be arrested by its resistance. The ex- 
tremity of the finger is passed slowly in between the viscera and the 
herniary orifice, depressing the intestine or omentum with the pulp 
of the finger. This stage of the procedure demands perseverance, for 
at first it seems impossible to succeed. The finger is next to be 
curved as a hook, and sufficient traction exerted on the ring to rup- 
ture some of the fibres, giving rise to a cracking yery sensible to the 



266 APPAKATUS FOE REMEDYING LOSS OF FUNCTION 

finger, and sometimes to the ear. When this characteristic crack is 
not produced, the fibres must be submitted to a continuous forced 
extension, which, by distending them beyond the agency of their 
natural elasticity, generally terminates the strangulation. This mode 
of procedure is less applicable to Gimbernat's ligament, the hooking 
and tearing of which are more difficult than in the case of the inguinal 
ring. Considerable strength has sometimes to be exerted, and the 
index finger becomes much fatigued. When, in consequence of the 
narrowness of the ring, the finger does not at once penetrate, it is to 
be pressed firmly against the fibrous edge, and inclined towards the 
hernia. After a time the fibres yield and the finger passes. When 
the finger becomes fatigued it is not to be withdrawn, but it should 
be supported by the fingers of an intelligent assistant, who seconds 
the action it is desired to produce. In inguinal hernia, the traction 
should not be exerted with the finger upon Poupart's ligament, but 
in a direction from within outwards, and from below upwards, by 
which the aponeurotic layers between the two ligamentous pillars con- 
stituting the inguinal aperture are easily torn through. 

"The ring is then enlarged by this tearing, just as if it had been 
divided by a cutting instrument, or largely dilated, and reduction 
takes place easily by performing the taxis in a suitable direction." 

Care should be taken that the whole mass of the hernia may not 
slip into the abdomen while the constriction remains unrelieved. If 
the accident should result, the patient should be directed to make 
straining efforts to reproduce the hernia, when the taxis may be 
again had recourse to ; if this be not successful, herniotomy alone 
remains to be performed, and this is then often followed by a fatal 
result. 

After the successful employment of the taxis in inguinal hernia, the 
patient should be kept in the horizontal position a few days, and an 
appropriate truss applied. 

2. Taxis of Crural Hernia. — The intestine passing through the 
femoral canal and saphenous opening in the fascia lata will form a 
tumor of smaller size than that observed in inguinal hernia, with its 
greater diameter transverse, and located at a point somewhat lower 
and a little external to the external abdominal ring. By placing the 
finger upon the horizontal ramus of the pubic bone the tumor will be 
found to be situated below it. 

From the peculiar conformation of the crural canal, in performing 
the taxis it will be necessary to place the patient in the horizontal pos- 
ture, and in order to relax the parts about the internal femoral ring 
and saphenous opening, flex the thigh upon the abdomen, adduct and 
rotate it inwards. Then the surgeon, having thoroughly anaesthetized 
the patient, he takes his place upon that side of him opposite the one 
upon which the hernia is situated, and grasps the tumor, if it has ap- 
peared above the falciform process of the saphenous opening, with the 
hand lying in the axis of the thigh, presses it downwards and a little 
inwards, until the intestine enters the infundibulum, when with the 
fingers of the other hand pressure is exercised upward and a little 
outward. Of course, if the intestine is found still in the infundibulum 



OF MUSCLES OF THE TRUNK. 267 

when the case is first seen, the latter part of this movement is only 
required, that is, pressure upwards and a little outwards. 

Crural hernia requires more caution in manipulating the reduction 
than the inguinal, in consequence of the firm and resisting nature of 
the fibrous barriers through which the intestine passes to the exterior; 
and more injury is therefore likely to follow the efforts to force it in 
a retrograde direction. For this reason the time employed in making 
the taxis should be much shorter. 

From the shortness of the omentum and the lower position of the 
crural canal, the tumor will be found most often to contain intestine. 
When the reduction has been accomplished, a properly constructed 
truss must be applied. 

3. Taxis of Umbilical Hernia. — The manipulations required to re- 
turn the extruded intestine in this variety of rupture are much more 
simple and less dangerous than in either of the two preceding varieties, 
for the reason that the point of issue is a simple aperture in the ab- 
dominal walls instead of a canal with sharp and resisting boundaries. 

Umbilical hernia occurs most frequently after birth, the aperture 
through which the vessel of the child passes to gain admission into 
the abdomen not being closed ; in the adult, it happens in a majority 
of cases in obese subjects. 

In employing the taxis, the surgeon takes the tumor in the palm of 
his right hand, and, having diminished its size by compressing it, with 
the fingers of the other hand at the umbilicus he makes compression 
directly backwards, until he may have effected the return of the con- 
tents of the hernia. If, from the size of the tumor or other causes, the 
bowel has descended below the umbilical ring, pressure will have to 
be made upwards and then backwards. When the reduction has been 
effected, one of the trusses already described must be applied. 

Loss of Function of the Sphincter Ani. Prolapsus Anl — This 
prolapse occurs both in infancy and in the adult, the former variety 
being much more amenable to treatment by mechanical means than the 
latter. It consists in its mildest form of the extrusion of the rectal 
mucous membrane beyond the sphincter, forming a globular shaped 
and transversely corrugated tumor; in cases of long standing, not 
only the mucous membrane but the muscular walls of the gut itself 
become prolapsed. In a case now under my treatment this condition 
of things exists, accompanied with so great a relaxation of the sphinc- 
ter ani that the whole hand can be introduced into the rectum with 
ease. 

Replacement of the Prolapse. — In the first class of cases mentioned, 
or those occurring in infancy, the reduction is easily accomplished by 
simply oiling the index finger and pressing upon the centre of the 
tumor, when the bowel will gradually recede within the sphincter. In 
large prolapses, when the above plan will not succeed, the patient may 
be placed upon his knees with the head supported by a pillow so as 
to give the pelvis a greater elevation than the rest of the body, and in 
order that the abdominal viscera may gravitate towards the diaphragm; 
then the surgeon, having washed the tumor, greases the ends of his 
first three fingers, places their tips upon the centre of the tumor, and 



268 APPAEATUS FOR REMEDYING LOSS OF FUNCTION 

presses the bowel within the sphincter ; or the patient may be placed 
upon his side with the thighs drawn up and the body flexed forwards 
so as to relax the abdominal muscles, and anaesthetized, when the above 
manipulation with the fingers may be practised. 

Retentive Apparatus. — The simplest form of a mechanical support 
that can be employed in mild cases of prolapse is to place, after the 
reduction of the bowel, a slightly convex pad over the sphincter, of 
sufficient size to extend beyond its margins, and secured by a T band- 
age. Some surgeons recommend the introduction into the rectum of 
an ivory or wax pessary to support the folds of its mucous membrane 
until they gain sufficient tone to resist extrusion. 

Fig. 173. Fig. 174. 




Apparatus for prolapsus ani. 



A more elegant method of making compression upon the sphincter 
is with an apparatus (Fig. 174) consisting of a well-padded belt for the 
loins, from the centre of which belt there projects posteriorly a flat 
spring bearing at its extremity a slight convex pad firmly stuffed with 
fine sand and covered with smooth buckskin, or a metallic plate with 
an India-rubber air-pad secured upon its upper surface of sufficient 
size to repose upon the margins of the sphincter. 

In the inveterate case above mentioned, under my care, I emploj^ed 
an apparatus composed of a loop of No. 6 wire, four inches long, and 
curved to fit the anterior surface of the sacrum, having a stem at its 
base an inch and a half long, and formed of the two wires of the loop 
twisted together. The end of this stem was soldered to a wire frame 
consisting of a single wire crossing the perineum antero-posteriorly, 
and dividing in front and behind into two branches terminating in 
large eyes, through which a cord was passed to secure the apparatus 
to the person. By this means the bowel was retained in its normal 
situation during defecation, by the instrument holding the posterior 
wall of the rectum against the curve of the sacrum. 

Loss of Function of the Uterine Ligaments and Yaginal 
Walls. Prolapsus Uteri. — There are two kinds of mechanical 
supports employed for the correction of prolapse of the uterus : the 
one internal, designated pessaries, a name derived from the Greek 
Ttsaoo, and supposed by some to come from rtsooeiv, "to assuage," by 
others from nsaxo^ the skin of an animal with hair upon it, in which 
the materials of a pessary were formerly inclosed before being intro- 



OF MUSCLES OF THE TRUNK. 269 

duced into the vagina ; the other external, and commonly called uterine 
supporters. 

1. Pessaries. — In former times pessaries were composed of various 
medicinal substances, and were introduced into the vagina with a view 
of obtaining their specific effects upon the mucous membrane; astrin- 
gent articles being frequently employed in this manner ; no stress was 
laid upon their use as mechanical supports ; but at present they are 
especially designed to obtain this object, and are prepared of such 
resisting materials and of such volume as to offer a mechanical ob- 
struction to the displacement of the uterus by taking points of support 
upon the vaginal wall and perineum, or they are sometimes supported 
by the aid of an exterior bandage. The material and shape of pes- 
saries have within the last two hundred years undergone innumerable 
modifications; those employed at the present day are manufactured of 
hard wood, certain of the metals (gold, silver, steel, iron wire), gutta- 
percha, gum-elastic, sponge, cork, &c. The shape is equally as various 
— globular, oval, discoid, conical, and horseshoe-shaped. 

Pessaries which take their points of support internally. — The instru- 
ments of this class enjoy a high reputation and are much employed 
in America. A simple pessary of this class consists of an oval or 
round discoidal-shaped instrument made of gutta-percha or boxwood, 
and perforated in the centre with a hole for the escape of the men- 
strual secretions, and which may also permit of impregnation taking 
place. This is introduced into the vagina by pressing the pessary 
held in the fingers of the right hand vertically, against the vulva 
while the left index-finger depresses the perineum, and then bringing 
it into a transverse position by pressing upon its edge so that it may 
catch upon each side of the vagina in the direction of the ischia. The 
instrument is liable to three objections: first, it cannot be manipulated 
so readily by the female herself; secondly, if the aperture in its centre 
is made too large, the neck of the uterus may pass through it and 
become strangulated (the latter objection may, however, be easily 
remedied by having the hole made too small for this part of the 
uterus to pass); thirdly, it is supported by a narrow band of the 
vagina, and is therefore easily displaced. 

Zwanck, of Hamburg, has successfully overcome these objections 
by a discoid pessary composed of two hollow and oval pieces of metal, 
united by a hinge which is moved by a curved stem connected with 
each disk. The instrument is introduced closed ; then by bringing 
the two stems together, and fixing them by a screw at their extremities, 
the disks are expanded. This pessary is well adapted to the severer 
cases of prolapse. 

Cloquet employed what he denominated an elytroid pessary, pre- 
pared in exact imitation of a model of the vagina, with the uterus in 
its normal position, taken with plaster of Paris. The instrument has 
a compressed cylindroidal form, concave anteriorly and convex pos- 
teriorly, to fit exactly the curve of the sacrum. Its upper extremity 
is concave, with its longest axis transverse; its lower expands laterally 
into two wing-shaped processes ; a canal runs its entire length, to give 



270 APPARATUS FOR REMEDYING LOSS OF FUNCTION 



Fig. 175. 



issue to the menses. It is 
supported in the vagina by 
the expanded lower extremity 
catching upon the inner sur- 
face of that canal above the 
labia majora. 

An elegant form of pessary, 
now coming into general use 
and possessing many advan- 
tages, consists of a ball of 
India-rubber connected with 
a tube of the same material 
about six inches long. This 
instrument (Fig. 175) is first 
emptied of air by pressing it 
in the hand, then introduced 
into the vagina and inflated 
by means of a second ball, of 
somewhat larger dimensions, 

also of India-rubber; the air is prevented from issuing again by 

closing a little stopcock at the end of the tube. 

The shape of the pessary may be varied, as may be seen in Figs. 

176, 177, and 178, and constructed with a central canal for the issue 




Mode of introducing the India-rubber pessary. 



Fig. 176. 



Fig. 177. 



Fig. 178. 




Different forms of India-rubber pessaries. 

of the menstrual secretions ; but as it is intended that the ball should 
be removed every night and cleansed, very little, if any, advantage is 
obtainable from these modifications. 

The India-rubber ball, presenting a large surface, comes in contact 
with a greater area of the vaginal walls, and therefore is better sup- 
ported by them, than any other kind of pessary. 

The softness and elastic nature of this material certainly produce 
the minimum amount of irritation that any instrument of the kind 
is capable of causing. An additional advantage is also presented in 
that the patient herself can introduce and remove the pessary when- 
ever she chooses, for vaginal ablutions, which should be sedulously 
practised every day; to prevent the lodgment of acrid or irritating 
secretions, or for other purposes ; there is no danger of her giving it 
a false position, nor does it require any skill to put the pessary in its 
proper place, two important circumstances which confer upon it a 



OF MUSCLES OF THE TEUNK. 271 

decided superiority over other instruments. It is particularly adapted 
to prolapsus of the third degree, when there is a large vagina and 
much relaxation of the surrounding parts. 

M. Diday employed this instrument successfully in plugging the 
vagina in uterine hemorrhage. Its advantages, according to him, are: 
"1. In its simplicity, and the rapidity with which it may be employed. 
Thus, it only weighs about half an ounce, is soft and flexible, admit- 
ting of being put in the instrument-case, and is applied in a few 
seconds. 2. It causes no pain, either during or after its application, 
and requires no bandage to retain it. 3. It admits, before insufflation, 
of being moulded on the parts to be compressed, and thus can exert 
compression upon a cavity, however irregular in form. 4. It allows of 
any degree of diminution or increase of pressure to be made, according 
to the exigencies of the case. 5. It is impermeable to and incor- 
ruptible by whatever discharges it comes into contact with, and never 
loses its elasticity. 6. Distended only to a third or fourth of its 
natural extensibility, it is just as smooth, and possesses nearly as great 
a resisting power, as when fully distended. 7. A somewhat larger 
apparatus would be available for plugging the cavity of the uterus 
itself, in hemorrhage after delivery. Moulded on the inner surface 
of that organ during its state of inertia, as this became recovered 
from, the air would be gradually let out, and the size of the compress- 
ing vessel diminished pari passu with that of the uterine cavity." 

Dr. Hodge, of Philadelphia, recommends a pessary composed of 
gutta-percha, and shaped as seen in the figure (Fig. 179). One of the 
shorter sides is introduced behind the cer- 
vix uteri when the instrument is placed Fl S- 179 - 
in the upper part of the vagina. From 
the peculiar shape of the lateral sides 
(that of the Italic letter s), the instru- 
ment is stated by him to possess the 
power of a lever, and, besides supporting 
the uterus, throws the fundus forwards, 
should it be displaced in retroversion. 
Before the pessary is introduced, it must 
be well oiled ; and the forefinger of the 
left hand of the surgeon being placed 
upon the fourchette, to depress the peri- 
neum, the instrument, held in the right hand, is presented to the vulva 
by one of its narrow ends, its width corresponding with the antero- 
posterior axis of the vulva, and is pressed gently in the vagina, and 
then twisted upon itself a quarter of a circle, until it lies transversely 
with its superior cross-piece fairly lodged in the cul-de-sac behind the 
neck of the uterus. 

Sponge has been employed as a pessary, and is either placed imme- 
diately in the vagina, or protected with a covering of linen or oiled 
silk; its advantages are cheapness, facility of putting it in place by the 
woman herself, and its immediate expansion supporting the uterus in 
its normal site. The disadvantages, however, of the material more 
than counterbalance these advantages ; it irritates the vaginal mucous 




272 APPARATUS FOR REMEDYING LOSS OF FUNCTION 

membrane, absorbs the secretions, and in consequence becomes rapidly- 
foul. If used at all, it must be restricted to slight cases of displace- 
ment, and must be removed every twelve hours to be thoroughly 
soaked in hot water and cleansed ; two or three pieces of the sponge 
may be thus used alternately. 

Bauhin employed pessaries of silver wire, and Prunel those of 
iron wire made in the shape of the frustrum of a cone, and rendered 
elastic by a series of superficial rings joined together, and covered 
with soft leather. M. Mayor extemporized pessaries consisting of a 
framework of iron wire, covered with carded cotton and oiled silk. 

Pessaries which are supported by an external bandage. — One of the 
oldest forms of this class of pessaries is the common bilboquet, which 
is an instrument shaped at its superior extremity to receive the cervix 
uteri, and terminating below in a stem to which is attached the straps 
to be fastened above to a pelvic belt. This method of supporting a 
pessary is liable to the objection that the movements of the patient 
displace more or less the pelvic belt, and thus urge the instrument 
against the os uteri. 

This pessary may be still further modified by constructing the 
stem hollow, so that the menstrual and mucous secretion may escape 
externally. 

An apparatus (Fig. 180), constructed by M. Gariel, deserves to be 
especially mentioned ; it is intended for severe cases of prolapse, 

attended with rupture of the recto- 
Fi #- 18 °- vaginal septum, when some external 

support becomes indispensable. It 
consists of an India-rubber pessary 
(c), fixed to the middle of a perineal 
band, which is supported in place by 
four thigh-straps {b, b, b, b), formed of 
rubber tubes fastened to a pelvic band. 
An aperture is made in the perineal strap, that the patient may mic- 
turate without displacing the bandage. 

These forms of the pessary are sometimes employed in connection 
with a broad abdominal bandage. 

2. Uterine Supporters. — In Europe, the tendency is to do away with 
internal uterine support in prolapse, and to substitute compression, with 
a bandage upon the sacrum, hypogastrium, or perineum. Dr. West 
remarks, in regard to instruments of this class : " One source of comfort 
to the patient, from the employment of some external supports, is de- 
rived from the counter-pressure on the pelvis which the belt exercises, 
and which relieves very many of the painful sensations experienced 
in cases of uterine prolapsus. The bandages which seem to me ex- 
tremely well adapted for this purpose are Hull's utero-abdominal 
supporter, and a bandage known by instrument-makers as Dr. Ash- 
burner's bandage. Each of them tightly embraces the hips, while 
the former is furnished with a large padded metallic plate fitting over 
the pubis, and the latter with a similar one adapted to the upper part 
of the sacrum. The chief utility of these metallic plates is that by 
their firm and yet gentle counter-pressure they relieve the sympa- 




OF MUSCLES OF THE TRUNK. 



273 



thetic pains referred to the back in one case, or the dragging and dis- 
tress in the region of the ovaries in another. To both of them a strap 
passing between the legs, with a perineal pad, is adapted; and though 
it can be dispensed with at pleasure, will be found of great service in 
all cases of considerable relaxation of the vagina, with disposition to 



Fig. 181. 



Fig. 182. 





Uterine supporter. Front and back view. 

actual procidentia, when used either alone or in combination with 
some form of internal support. The strap and perineal pad have the 
disadvantage of heating the parts, aud thus of keeping up leucorrhceal 
discharge; but without them the instrument cannot be so well 
adjusted. Of the two, that of Dr. Ashburner, with its sacral pad, has 
seemed to me the more useful, greatly relieving the back-ache, and 
being found, indeed, by some persons, almost indispensable to their 
comfort in walking or making any kind of exertion." 

In the apparatus seen in Fig. 183, the pad is constructed with a mova- 
ble plate and ratchet arrange- 
ment, controlled by a key, so that Fi S- 183 « 
the pressure may be graduated 
to the necessities of each case. 
The two lateral metallic springs, 
attached to the plate, are fast- 
ened behind by strap and buckle. 
A much simpler supporter may 
be constructed after the manner 
of "Hood's Truss," already de- 
scribed ; the anterior pads, which 
are to rest above the pubis, however, should be larger than in that 
instrument. 

Introduction of Pessaries. — We have cursorily glanced, under the 
description of each instrument, at the method of introduction required 
by its individual peculiarities ; and therefore a few general remarks,, 
applicable in these respects to all of them, will be required in this 
place. 

The position that a patient should take while a pessary is being 




Uterine Supporter. 



274 APPARATUS FOR REMEDYING LOSS OP FUNCTION 

introduced, may be one of recumbency upon the back or left side, 
with the legs flexed and the thighs drawn up so that the abdominal 
muscles shall be placed in a state of the most perfect relaxation pos- 
sible. Then the uterus having been pressed into its natural site, the 
surgeon greases the pessary thoroughly, and gently presses it into the 
vulva, and as high up into the vagina as the cul-de-sac behind the 
os uteri, where it is retained, if of the proper size, by the contractile 
power of the vagina alone. From an unusual sensitiveness or irrita- 
bility of the part, a sufficiently large instrument cannot be introduced 
at first; but one of smaller dimensions will have to be selected and 
used until the canal becomes accustomed to its presence, when it may 
be replaced by a still larger one. Injections and the hip-bath, with 
rest in the recumbent posture, will materially aid in enabling the 
parts to tolerate the foreign body. Inflammation, or any considera- 
ble congestion of the uterus, will contraindicate its employment until 
those have been controlled by appropriate medication. 

When the pessary has been put in the position intended, the patient 
should be directed to move about the room and to cough, in order 
to ascertain if it will remain fixed, and does not cause pain or 
uneasiness. 

The instrument sometimes causes difficulty in urination or defeca- 
tion, numbness of the legs, or some pain or unpleasant sensation in 
the small of the back, requiring the instrument to be changed for 
another, and the use of emollient injections. 

Pessaries, prepared of any material whatever, should not be kept for 
many days together in the vagina, as a calcareous deposit will take place 
upon their surface, producing much irritation and even ulceration of the 
surrounding parts, and they have been known to establish both vesico- 
vaginal and recto- vaginal fistulas. Daily ablutions will diminish in a 
measure this incrustation, and prevent the accumulation of fetid secre- 
tions. In some patients they may require removal and washing every 
twenty four hours, in others every four or five days will suffice ; in 
general it will not be advisable to delay it beyond the latter period. 

Should the tone of the vaginal walls and uterine ligaments be re- 
stored, and a cure of the prolapse deemed secure, it will be requisite 
to decrease, by degrees, the size of the instrument, and then gradually 
abandon its use. 

The removal of a pessary is accomplished by placing the female in 
the same position as we have stated for its introduction, and then with 
the finger it may be hooked and drawn out; or the loop of a cord 
may be passed over some part of it and used as a means of traction. 

SECTION III. 

APPARATUS FOR REMEDYING LOSS OF FUNCTION OF PARTS OF THE 
UPPER EXTREMITIES. 

Loss of Function of Muscles of Fingers. — Writer's cramp, 
sometimes called chorea scriptorum, consists in a spasmodic action of 
the flexor muscles of the thumb and fingers, which either contract 
rigidly or irregularly in such a manner that a pen cannot be controlled 



OF PARTS OF THE UPPER EXTREMITIES, 



275 



in writing, though in all other movements in which the muscles partici- 
pate no difficulty from this source is encountered. Sometimes the 
extensor muscles suffer instead of the flexor. This spasmodic action 
is seen also in other muscles which are directly employed in any par- 
ticular manner, as those of the leg in turning the lathe, and those con- 
cerned in guiding the needle in sewing, printing, fingering musical 
instruments, &c. 

Treatment. — Absolute abstinence from the exciting causes is the only 
means necessary in certain cases to effect a cure, while others are per* 
sistent for weeks or months, or lastly, others again may be incurable. 
The chances of recovery are greater or less in proportion to the num- 
ber of muscles affected, as, for instance, where it affects only those of 
the thumb or of a single finger. More hope of alleviation may also 
be entertained from the means employed in these cases where the move- 
ments habitually executed require the co-ordination of fewer muscles 
to execute them ; the hand of a shoemaker or printer may be relieved 
by mechanical appliances, which will 
enable them to resume their avocations; 
while, on the contrary, the same amount 
of spasmodic action in the hand of a 
musician could not be sufficiently di- 
minished by the same apparatus to 
enable him to pursue his profession. 
The mechanical apparatus which have 
been suggested for the alleviation or 
cure of this remarkable spasmodic ac- 
tion of the muscles of the hand in the 
classes of persons above mentioned are 
ingenious. Yelpeau invented one (Fig. 
184) consisting of an ovoid handle to 
which is attached a tube for carrying the pen, and two metallic rests 
for the index and middle fingers. 

In mild cases, the little instrument seen in Fig. 185 will be of essen- 
tial service in restraining the abnormal contraction of the muscles. It 



Fig. 184. 




Velpeau's apparatus for writer's cramp. 



Fig. 185. 



Fig. 186. 





Apparatus for writer's cramp. 



Apparatus for writer's cramp. 



is simply a pen holder supported between the rings A A fitting on the 
index finger and the thumb-piece B. 

To relieve the muscles of the thumb entirely, the pen may be sup- 



276 APPARATUS FOR REMEDYING LOSS OF FUNCTION 

ported by the index and middle fingers only. This may be conveni- 
ently effected with the contrivance seen in Fig. 186; it resembles the 
frame of a pair of spectacles, the rings of which, c c, fit over the tips 
of the index and middle fingers; between them there is a third ring 
to support the pen which is clamped in it by the thumb-screw D. 

Others have endeavored to antagonize the muscles by springs and 
India-rubber cords, or to restrain their abnormal action by making 
pressure upon them with a sort of mitten woven of rubber and silk. 
The same result may be obtained by two accurately moulded splints 
to the radial and ulnar sides of the hand and connected together by 
an elastic band. 

Cazenave invented an apparatus consisting of a penholder armed 
with two compressing screws, and two circles of India-rubber, each 
provided with a return screw. 

In the absence of more perfect apparatus, relief will be derived from 
simply fixing an ordinary penholder upon the fingers with a ribbon. 

Sometimes continuous pressure exercised upon the arm by a laced 
bandage will be followed by an alleviation of this distressing disease. 

Loss of Function of the Interossei Muscle of the Fingers. — 
A result, sometimes observed of the action of lead poison, or of some 
injury, is to cause a paralysis of the interossei muscles of the fingers, 
which then assume that peculiar position which has been called by 
French surgeons "main au griffe." The first phalanges are extended 
upon the metacarpal bones, by the common extensor not being antago- 
nized, while the second and third phalanges are drawn down or flexed 
upon the first in such a manner as to resemble the claw of a bird. 

After the removal of the cause, whatever that may be, upon which 
this disease depends, by appropriate medication, electrization, &c., the 
restoration of the functions of the affected muscles may be materially 
assisted by mechanical means. 

Fig. 187. 




Apparatus for paralysis of the interossei muscle. 



For this purpose M. Duchenne has invented the following very in- 
genious piece of mechanism (Fig. 187). 

A metallic stem is secured to the anterior surface of the forearm by 
a laced wristlet, c, its lower extremity is articulated to a plate B, fitted to 
the palm, by a joint f, admitting lateral motion only ; a second metallic 



OF PARTS OF THE UPPER EXTREMITIES. 277 

plate A. with four grooves, is jointed to the first with ginglymoid motion, 
and intended to be applied to the palmar aspect of the fingers, to which 
it is fastened by a strap passing across their dorsal surface. To the 
lower edge of this piece a spiral spring D is attached by one of its ends ; 
the other end has a gut cord fastened to it, which, after running through a 
hole in the top of a metallic pin little more than an inch long, and erected 
upon the palmar plate, passes through a ring near the articulation at 
the wrist, and is then reflected to the lower radial corner, G-, of the second 
plate, to be tied to a hole placed there for this purpose. From the outer 
border of the palmar plate two metallic stems also project, and are each 
supplied with a spiral spring H, I, and a catgut cord, the latter intended 
to be fastened to two little button-like projections placed respectively 
upon the posterior and anterior aspects of the upper portion of the 
wristlet. The action of the apparatus is simple ; the articulation of 
the wrist-stem with the palmar plate keeps the hand extended, and per- 
mits abduction and adduction to be exercised by the two lateral springs 
and gut cords. The second or digital plate serves the purpose of a splint 
in keeping the fingers straight, and permits their flexion by its move- 
able connections with the palmar piece, and is under the control of 
the spring and cord passing over the pulley in the palm. 

Loss of Function of the Extexsor' Communis Digitorum. — 
Paralysis of the common extensor of the fingers sometimes results from 
the impregnation of the system with lead, and is characterized by the 
inability of the patient to extend the first row of phalanges upon the 
metacarpus ; the flexors of the fingers being unopposed contract, some- 
times so energetically as to produce almost a subluxation of the meta- 
carpophalangeal articulations. As shown in wrist-drop, if the disease 
has been of long standing and the muscles atrophied, very little benefit 
can be expected from any plan of treatment, either therapeutical or 
mechanical. A number of apparatus have been suggested by surgeons 
to remedy this distressing condition. Of these none possess more 
merit than the one employed by that ingenious and learned physician 
M. Duchenne, of Boulogne (Fig. 188), constructed after the model of an 

Fig. 188. 



Apparatus for paralysis of the extensor communis. 



apparatus originally devised by M. Delacroix, and described by B£. 
Gerdy. It is composed of a laced wristlet, to which is attached a me- 
tallic plate A, fitting the posterior and lower part of the forearm ; to the 
inferior extremity of this another plate, B, is articulated by a joint H, 



278 APPARATUS FOR REMEDYING LOSS OF FUNCTION 

working laterally, moulded to the dorsum of the hand, and secured by 
a strap crossing the palm; to make it lighter and to permit the in- 
sensible perspiration to escape, three fenestra are made parallel with 
its length. Four short stems, somewhat raised from the fingers, are 
soldered to the lower edge of the dorsal plate, furnished with little 
pulleys over which gut cords d play, connected at one extremity to spiral 
springs attached to the plate, and at the other to four little rings E en- 
circling the fingers at the second phalangeal joints. Two other spiral 
springs, F, are fixed to the forearm plate, and continued, by means of two 
cords passing through a bracket soldered to its lower radial corner, 
to two rings, G, placed around the thumb. If the extensors and 
flexors of the hand are intact, a joint may be placed in front of the 
articulation at the wrist, so that the hand may be extended and flexed 
by the action of those muscles. The action of this contrivance is to 
assist the paralyzed common extensor of the fingers and the extensors 
of the wrist. 

Loss of Function of the Extensors of the Hand. — Paralysis 
of the extensor muscles of the hand is most commonly observed in 
painters, and those who use lead paints. It results from the poisonous 
influence of that metal when intromitted to the system. The par- 
alysis is not confined exclusively to these muscles, but affects generally 
the common extensors of the fingers to a greater or less extent ; the 
first row of phalanges cannot in consequence be raised to a level with 
the metacarpal bones, while, as a general thing, the second and third 
phalanges can be extended. It should also be further remarked that 
control over the flexor muscles of the hand may be to some extent 
impaired. The disease belongs to the class of bilateral or symme- 
trical affections, yet the corresponding muscles are not commonly 
affected in an equal degree, being more marked upon one side than 
upon the opposite. The extensors of the feet are occasionally affected 
in the same manner, so that the toes drop when the feet are raised in 
performing the act of locomotion, compelling the patient to step high, 
that the toes may not catch against the ground. 

The paralysis is sometimes readily cured by appropriate medication, 
while a considerable number obstinately resist all treatment, and be- 
come permanent, the muscles 
Fi §- 189 - undergoing atrophy and de- 

generation, conditions which 
render a cure, in the major- 
ity of cases, forever hopeless. 
PW^iff ' ! * 8 S$^\ The mechanical treatment 

can scarcely do more than 
afford some alleviation to 
this distressing condition. 
In certain cases an apparatus 

Apparatus for paralysis of the extensors of the hand. . _ , rr . , 

consisting or a laced wristlet 
(Fig. 189) extending half way up the forearm, from the roots of the 
fingers, composed of slips of India-rubber, will confer some extent 
and firmness of the grasping power. 




OF PARTS OF THE UPPER EXTREMITIES. 279 

Loss of Function of the Biceps of the Arm. — Paralysis of the 
flexor muscles of the forearm, resulting from traumatic or other 
causes, inflicts upon a patient a serious drawback to the utility of the 
upper extremity in the pursuit of his avocation. 

The functions of this muscle may be temporarily supplied by 
mechanical means, which will at the same time promote ultimate 
restoration of the limb by enabling the patient to exercise the injured 
muscle — a condition requisite to the re-establishment of its healthy 
tone. 

The apparatus (Fig. 190) for this purpose is very simple, consisting 
of two padded straps to embrace respectively the arm and forearm, 
and connected together by two laternal metallic bars jointed at the 
elbow ; a padded plate extends between the joints posteriorly to receive 
the olecranon, and to offer a solid resistance to the displacement of the 

Fig. 190. 




Apparatus for paralysis of the biceps. 

elbow backwards when the arm is flexed. The motive power intended 
to supplement the action of the biceps muscle is obtained by using two 
elastic cords placed upon each side of the arm and extending between 
the anterior portions of the side levers and the middle point of the 
arm strap. These cords, by their elasticity, flex the arm after it has 
been extended by the voluntary efforts of the patient. 

Loss of Function of the Scapular Muscles. — The large and 
powerful muscles which contribute largely to retain the head of the 
humerus in the glenoid cavity — the deltoid, spinate, and scapular — may 
become so relaxed as to permit the bone to become dislocated upon 
the application of slight exciting causes, and when this condition is 
also associated with relaxation of the capsular ligament, as it usually 
is, to a greater or less degree, the bone slips from its socket spontane- 
ously. The most obstinate cases of this kind originate from paralysis 
of the above-mentioned muscles after contusion of the shoulder, the 
humerus becoming spontaneously displaced, and the arm elongated 
and pendent. These muscles, in such examples, undergo atrophic 
degeneration ; the deltoid, especially, has been observed to be reduced 
to- almost a membranous condition, scarcely exhibiting any muscular 
fibres. In course of time the bones and cartilages entering into the 
structure of the joint also participate in the atrophy. These morbid 
changes frequently occupy many months in running their course. 



280 APPARATUS FOR REMEDYING LOSS OF FUNCTION 

Treatment. — The proper treatment consists in combating the inflam- 
matory condition of the constituents of the joint by counter-irritants, 
as blisters, the actual cautery, and stimulating applications, particularly 
the oil of turpentine. 

As it is desirable to maintain the functions of the limb intact, and 
yet secure the retention of the humerus in its socket, the best appa- 
ratus that can be employed is the following : "With gutta-percha sheets, 
softened in hot water, make a mould of the upper half of the arm, as 
far as the acromion process, also one of the shoulder, and a small por- 
tion of the chest, connect them together by a narrow India-rubber rib- 
bon at the point corresponding with the shoulder-joint. That part 
of the apparatus upon the chest can be secured by a circular lacing 
belt surrounding the body. By means of this arrangement the head 
of the humerus will be held in the glenoid cavity, while the arm is 
being exercised in its natural functions. 

Some persons have endeavored to secure the retention of the hume- 
rus by preparing and applying a solid gutta-percha splint to both the 
upper half of the arm and shoulder. 

Still a third plan has been employed with success. It requires a 
short crutch to be placed in the axilla, supported by a broad band 
passing from its lower extremity over the opposite shoulder. A 
second band encircles the chest and injured arm, so as to maintain the 
latter immovable. 

SECTION IY. 

APPARATUS FOR REMEDYING LOSS OF FUNCTION OF PARTS OF THE 
LOWER EXTREMITIES. 

Some of the most difficult and trying cases, to the surgeon, of loss 
of function of the muscles and ligaments occur in the lower extre- 
mities, from paralysis, debility, gout, and rheumatism, particularly 
from the first-mentioned disease, which, as it commonly results from 
centric causes, or morbid changes in the nervous masses themselves, 
is always of serious import, demanding that the efforts of the phy- 
sician should be first directed to the relief of these important struc- 
tures, upon the integrity of which the exercise of the functions of the 
muscles depends. In those cases where the patient survives the first 
shock of paralytic disease, and the nervous tissues wholly or partially 
regain, as they sometimes do, their capacity for originating or con- 
ducting the stimulus of the will, after the lapse of a longer or shorter 
time, a great deal may be accomplished in furthering the resumption 
of the lost muscular motility, by having recourse to suitable mechani- 
cal contrivances, composed of levers and elastic cords, to support the 
weight of the patient's body, and to supplement the lost or impaired 
functions, until the muscles shall have regained sufficient power to 
execute their natural offices. 

The difficulties in the mechanical treatment of these cases will be 
increased, in proportion to the extent of the parts involved, and the 
prognosis will depend upon the nature of the cause disabling the 
muscles ; for instance, the paralysis of the tibialis anticus, or peronei 



OF PARTS OF THE LOWER EXTREMITIES. 



281 



muscle, from local causes, is much more readily and quickly cured by 
suitable apparatus than the same disease originating from central causes, 
or changes in the encephalon or spinal marrow. Most frequently, 
it must be confessed, the larger proportion of cases fall into the latter 
category, and they vary much in their severity and extent. From 
some hitherto unexplained cause the extensor are more frequently 
affected by paralysis than the flexor muscles. The disease may involve 
the muscles generally, when the paralysis is said to be general, or may 
be confined to one limb or portion of the body — partial paralysis ; 
when certain muscles or groups of muscles suffer, the paralysis is 
said to be local. 

Loss of Function of the Tibialis Anticus. — Paralysis of the 
tibialis anticus is sometimes observed to be associated with central 
disease of the brain and spinal cord, but the most marked examples 
are those originating in impregnation of the animal economy with 
lead. Its characteristic features are inability to flex the foot upon the 
leg, which, in walking, drags along the ground, the toes striking against 
every obstacle. The affection is the analogue of " drop-wrist," and 
has been, not inappropriately, named ''drop-foot." 

In club-foot this muscle sometimes becomes so much elongated that 
after the operation of section of the tendo-Achillis, it does not con- 
tract, and maintain the foot in its normal relation with the leg, even 
after using appropriate apparatus. 

Treatment. — The treatment of this disease consists in employing, 
along with the therapeutical remedies, iodide of po- 
tassium, cold douche, electricity, &c., a mechanical 
contrivance constructed in the following manner: 
Fasten a steel lever, jointed at the ankle upon the 
inner side of the leg, by attaching its lower extremity 
to the sole of a boot, and the upper extremity to a 
padded strap surrounding the leg below the tubercle 
of the tibia. Solder to the lever above the ankle- 
joint a curved metallic rod spanning the instep, and 
supporting at its extremity in front an aperture 
through which an elastic cord passes, connected 
below to the sole of the boot near the toe and above 
to the leg-strap. This cord serves the purpose of an 
artificial tibialis anticus, and lifts the toes when the 
patient is walking, so that they do not strike against 
the irregularities of the surface over which he passes, 
nor do they drag along the ground. 

In the annexed illustration (Fig. 191) is shown 
an apparatus which may be employed when, besides 
the paralysis of the tibialis anticus, there is also de- 
ficient power in the extensors of the leg. The upper 
elastic cord extends the leg while the lower one 
raises the toes during the time the patient is walk- 
ing. The rest of the apparatus is similar to the one 
described above. 

Loss of Function of the Peronei Muscles. — The peronei mus- 




Apparatus for para- 
lysis of the tibialis an- 
ticus. 



282 APPAKATUS FOE REMEDYING LOSS OF FUNCTION 



cles are sometimes involved, along with the tibialis anticus, in para- 
lysis, and then, besides being unable to flex the foot, the patient cannot 
abduct it. 

Treatment. — This morbid condition requires, therefore, another form 
of mechanism than the one previously described to meet the necessi- 
ties of the case. It consists of a side-stem articulated below to the 
middle of a short lever fastened by its posterior extremity to a short 
upright springing up from the heel of the boot. An elastic cord 
connects the anterior point of the lever with the padded leg-strap 
above, and by its action, both flexes and abducts the foot. 

Loss of Function of the Extensor Muscles of the Legs. — 
We have alluded, in the previous instances, to paralysis affecting 
isolated muscles or a group of muscles of the lower extremities, and 
the instruments required for their treatment. In other cases, and 
indeed the majority of those that will come under the care of the 
surgeon, the paralysis extends to most of the muscles of both lower 
extremities, constituting paraplegia ; or it may be confined to one of 
them, and this conjoined with a similar condition of the corresponding 
upper extremity, is then called hemiplegia. Of course in all these 
cases pharmaceutic medication, friction, galvanism, cold douche are 
to be had recourse to ; and, after acute symptoms, if there have been 
any present, have subsided, and the patient so far recovered as to be in 
a suitable condition for moving about his room, or indeed for going out 
into the open air, the surgeon should endeavor, by mechanical con- 
trivances, to aid the faltering muscles, and support the weight of the 
body during the time the patient is exerting himself in walking. In 
this manner the debilitated or paralyzed muscles will be stimulated 
to contract and to resume, to a greater or less extent, their wonted 
vigor. 

Treatment. — The ordinary frame (Fig. 192) had recourse to in such 

cases will answer quite well 



Fig. 192. 




Supporting frame for paralysis of the lower extremities. 



in sustaining the patient 
erect while he exercises his 
legs in walking. The frame 
consists of two short crutches 
supported upon and sliding 
in a padded wooden ring, 
connected at a convenient 
height with a square frame 
borne by four upright arms 
moving upon castors. 

The patient supported in 
this mechanism can, when 
his legs are braced with the 
apparatus described below, 
propel it forwards by the 
mere act of stepping. 

In paralysis of a single 
lower extremity the appa- 
ratus (Fig. 193) required to 



OF PARTS OF THE LOWER EXTREMITIES, 



283 



restore the lost muscular functions will consist : 1st. Of an external 
lever extending from a well-padded thigh strap to near the middle 
of the sole of the boot, articulated at the knee and ankle-joints ; 2d. 
An internal lever, jointed at the knee and ankle, supported above by 
the thigh-strap, and connected to the sole in the same manner as the 
first lever; the apparatus is ren- 



Fig. 193. 



Fig. 194. 



dered still more firm by a padded 
strap connecting the two levers 
together below the knee; 3d. Two 
elastic cords stretching between 
the sole and the leg-strap, to flex 
the foot; and two other cords at- 
tached below to a short lever pro- 
jecting anteriorly from the knee 
articulation, and above to the 
thigh-strap ; these extend the leg 
upon the thigh. To carry the 
whole limb forward three elastic 
cords are employed, fastened be- 
low to a steel arc spanning across 
the knee and above to the pelvic 
band. The two levers are curved 
forward at the ankle so that they 
may be attached to the centre of 
the sole of the boot, and thus 
facilitate the lifting of the toes 
when the patient steps forward. 
Where there is a constant dispo- 
sition of the knee to yield in a 
forward direction by the weight 
of the body, I sometimes use an- 
other form of artificial support (Fig. 19-i), in which the elastic cords 
are discarded and the knee is locked by the metallic rods extending 
between the straps posteriorly, as seen in the figure. 

These apparatus will be found efficient in those cases of paralysis 
where the two limbs are of the same length ; in other instances the 
paralysis takes place during childhood, originating, perhaps, in the 
majority of cases, from perverted innervation depending upon some 
disease of the brain or spinal cord; the development of the limb is 
arrested, and the patient grows to adult age with more or less diminu- 
tion in its length and volume. For such persons the foregoing 
instruments will have to be somewhat modified by the addition of a 
thick-soled boot to render the limbs uniform in length. 

When the paralysis involves both lower extremities, a still more 
complicated mechanism (Fig. 195) will be demanded. It consists of 
two levers extending from the axillas to the soles of the boots, pro- 
vided above with crutches, and articulated at the hips, knees, and 
ankles. These are secured to the body by means of thoracic and 
pelvic belts, thigh and leg-straps, and broad bands around the knees. 





Apparatus for paralysis of one extremity. 



281 APPARATUS FOR REMEDYING LOSS OF FUNCTION 



The India-rubber cords to imitate the action of the muscles are placed, 
as in the other instrument, at the hips, knees, and ankles. This appa- 
ratus may be occasionally modified with advantage by an arrangement 
which will enable the surgeon to lock the knee-joints by means of 
metallic rods connecting the straps upon the limb. (Fig. 196.) 

In the beginning of the treatment of a case of paralysis of the lower 
extremities, the latter form of apparatus should be generally preferred, 
as the patient can get along better with it than when motion is per- 
mitted at the knee-joints ; as it possesses more stability, he feels greater 
confidence, and will step out boldly, without fear of his knees yielding 
beneath him. 

After the patient has gained some control over his limbs the rods 
may be removed and elastic cords substituted. 



Fig. 195. 



Fig. 196. 





Apparatus for paralysis of both extremities. 

Loss of Function of the Ligaments of the Knee-Joint 
(Knock-Knee, Genu-valgum). — This affection, next to rachitic cur- 
vature of the bones, is perhaps the most common deformity met with ; 
it occurs at any period of life from infancy to adult age, and is rarely 
or never seen in vigorous manhood or old age. It is never congenital, 
and after infancy is, perhaps, most frequent between the ages of ten 
and eighteen years. Though the higher classes are not exempt from 
its attacks, yet it is found chiefly among the poor and ill-fed classes of 
society. This deformity is seen in Fig. 197. 

The pathology of the disease has been shown to consist in a relaxed 



OF PARTS OF THE LOWER EXTREMITIES 



285 




condition of the internal lateral and posterior crucial ligaments of the 
knee-joint, so that the articulation gains other than anteroposterior 
motion, the only one it pos- 
sesses in its normal condition. Fi g- 197. 
The leg, when flexed, has its 
ordinary position and rela- 
tions ; partially extended, the 
tibia rotates obliquely out- 
wards, and in full extension, 
instead of being in a straight 
line it rotates laterally, leav- 
ing a space between the inner 
condyle and the head of the 
tibia. It is believed by some 
pathologists that the external 
condyle, being more pressed 
against than the internal, is 
arrested in its growth, when 
the disease has lasted from 
infancy, so that the inner con- 
dyle becomes disproportion- 
ally large and altered in 

figure, and causes the oblique Knock-knee, 

outward rotation of the tibia 

observed to take place. Mr. Tamplin, on the other hand, does not be- 
lieve that an actual enlargement takes place, but that it is only appa- 
rent in consequence of the gastrocnemius not following altogether the 
position of the condyle, but recedes from the tibia and femur on the 
internal side and passes in a more direct line to its origin. There is, 
however, an enlargement of the tubercle of the tibia sometimes ob- 
served. 

Knock-knee is often found associated with rachitic curvature of 
the femur and bones of the leg, and sometimes in infancy curvature 
of the leg bones occurs without this disease, but after ten years of 
age this result never occurs. In infancy, also, the malposition of the 
limb causes the astragalus to assume an oblique position, so that, with 
the yielding of the internal lateral ligaments of the ankle-joint, a 
spurious talipes valgus is produced ; very rarely a true valgus, with 
paralysis of the tibialis anticus muscle, has been encountered. 

One of the serious complications of knock-knee is curvature of the 
spine, resulting from obliquity of the pelvis in consequence of the 
unequal yielding of the two legs, which almost always happens in the 
course of the deformity ; so that, to restore the equilibrium of the 
body, a curve must be formed in the spinal column with its convexity 
looking to the side with the longest leg. The disease is seen some- 
times to affect but one knee ; and again, in rare examples, the oppo- 
site knee curves outwards (Fig. 198); in these cases, for obvious rea- 
sons, spinal curvature progresses with greater rapidity. 

It has been already stated that the predisposing cause to knock- 
knee is debility; the exciting causes are said to be the irritation of 



286 APPARATUS FOR REMEDYING LOSS OF FUNCTION 



Fig. 198. 



teething, the eruptive fevers carrying heavy burdens, and standing 
erect too incessantly, as is required of youths in certain factories 

during their hours of 
labor. When the knees 
once begin to yield, the 
weight of the body, act- 
ing to a greater advant- 
age upon the legs, causes 
the disease to progress 
with greater rapidity. 

Treatment. — The treat- 
ment of knock knee me- 
chanically is attended 
with great success, but it 
should always be associ- 
ated with alteratives, to- 
nics, nutritious food, and 
fresh air, to obtain speedy 
and lasting results. 

In considering the me- 
chanism of knock-knee 
with a view of obtaining 
correct mechanical prin- 
ciples upon which to con- 
struct our apparatus, we 
shall find that there has 
occurred a deviation in 
the shape of the limb, 
which normally repre- 
sents a vertical column 
supporting the body 
upon its apex in the direction of the line of its axis, the extremi- 
ties and fixed points of which are respectively at the acetabulum and 
ankle-joint. If now the internal lateral and posterior crucial liga- 
ments yield, the knees will move inwards towards each other, and 
the body will then be supported in the direction of a broken line 
passing through the femur and tibia, and representing two sides of a 
triangle, the base of which is formed by the normal axis of the limb, 
and its apex by the knee-joint itself; the feet, receiving this weight 
in an oblique direction outwards, which the legs have now assumed, 
will be removed to a greater distance from each other, a condition 
which is always observed in this affection. An apparatus, then, to 
counteract it, should be a lever running parallel with the normal axis 
of the limb, and have two fixed points of resistance corresponding 
with the extremities of this axis, with straps or other contrivances 
acting from its centre upon the knee-joint from within outwards ; in, 
other words, from the apex of the triangle to its base. 

The lever should not be jointed, at least in severe cases ; as, when 
it possesses a centre of motion at the knee, every time the leg is bent 
the apparatus tends to rotate inwards at the hip, thus destroying the 




Knock -knee with outward curving of the opposite knee. 



OF PAETS OF THE LOWER EXTREMITIES 



287 



Fig. 199. 




force of the bands acting upon the knee; although in milder cases, or 
after the limb has been straightened by an inflexible stem, a jointed 
mechanism may be employed with advantage. Indeed, an instrument 
in general use is constructed upon this plan. It consists of a lateral 
splint, connected above to a padded pelvic strap, below to the soles of 
the boots, and jointed at the hip, knee, and ankle joints. Two straps 
are affixed to the stem, one to the thigh lever, which passes across the 
popliteal space and head of the tibia, to be buckled to the leg lever 
in front ; another to the leg lever, which 
crosses the former in a reverse direction, 
to be attached to the stem above the knee. 
By this arrangement the straps support 
and act both upon the head of the tibia 
and the condyles of the femur. 

Another simple contrivance is shown 
in Fig. 199. It is composed of two con- 
cave splints connected together at the 
knee, one fitting the outside of the thigh, 
and the other the corresponding surface 
of the leg. The upper extremity of the 
thigh-piece bears a metallic stem, to which 
a pelvic strap is fastened ; while the lower 
end of the leg portion is attached to the 
sole of the boot by a rectangular pin fit- 
ting into a socket. The requisite amount 
of lateral traction is obtained by the cir- 
cular straps shown in the illustration, connected with splints and 
surrounding the limb. 

The straps in these forms of apparatus do not secure the limb to 
the lever with much firmness, and therefore much of their tractile 
power is lost when the legs are being used. To remedy this disad- 
vantage to some extent, it is only necessary to substitute for the 
two knee-straps broad metallic thigh and leg-bands, well padded, and 
fastening to the limb with narrow leather straps and buckles. These 
bands, with a broad knee-cap, secure the limb firmly, and answer 
every requirement. 

Another form of instrument may be employed in mild cases, and 
worn under the ordinary garments of the patient without being de- 
tected. The jointed side-stem is attached above and below to padded 
metallic thigh and leg-bands, while the knee is drawn outwards by a 
broad webbing knee-cap. 

In the formation of knock-knee, the theory " that the lower part of 
the leg (tibia and tarsus) rotates from the inferior extremity of the 
femur, in an outward direction, and that the thigh always holds its 
original and perfect position," is held by some surgeons, and Mr. Hes- 
ter, of London, based upon this view the construction of an apparatus 
(Fig. 200) which is thus described by Mr. Bigg: "It is constructed of 
two levers, with a large hollow-jointed disk at their point of junction, 
which receives the internal condyle within its circumference. Of 
these levers one corresponds with the proper line of the thigh, the 



Apparatus for knock-knee. 



288 APPARATUS FOR REMEDYING LOSS OF FUNCTION 



Fig. 200. 




Hester's apparatus for 
knock-knee. 



Fig. 201. 



other with that of the leg, and both terminate by padded metal bands, 
those above the thigh, these below the calf. When the upper stem is 
fixed firmly to the thigh, a space is left between 
the inferior extremity of the lower stem and the 
internal malleolus of the tibia, proportional, of 
course, to the angularity of the limb ; which space 
must be reduced by fastening the lower padded 
band as tightly as the patient can bear it." He 
also remarks that, " in the mechanical action of this 
instrument, the thigh-lever becomes a fixed point, 
its major fulcrum being situated at the inner con- 
dyle; while, as the resistance to be overcome is 
afforded by the lower leg, the calf-band presents 
the required means for reducing the space between 
the tibia and leg-stem. Kneeling can be performed 
at pleasure during the whole period of treatment, 
the knee-disk forming a ring-joint." In a severe 
case treated by me with this apparatus, it did not 
afford satisfactory results, and was abandoned; 
though in milder cases, I think, it would succeed. 
An excellent form of appliance (Fig. 201), in severe cases of knock- 
knee, is constructed with a lateral lever connected above to a pad- 
ded pelvic belt, and below to the sole of the 
boot; the stem has joints at the hip and 
ankles, while, at the knee, there is a ratchet 
arrangement controlled by a key, by means of 
which it may be bent laterally to conform to 
the outer and concave sweep of the limb. To 
the stems are attached padded metallic thigh 
and leg-straps and a webbing knee-cap. By the 
gradual extension of the levers the knee is 
drawn outwards, and the extremity straight- 
ened. 

If there should be contraction of the knees 
along with the deformity, the addition of a 
second ratchet- screw to this instrument at the 
knee-joint, acting antero- posteriorly, will be re- 
quired. Where the more elaborate apparatus 
cannot be obtained; an extemporaneous con- 
trivance, described by Mr. Tamplin, may be 
used. " A splint made of two zinc plates, one 
portion to correspond with the thigh, the other 
with the leg; there is a straight piece of iron or wood attached by a 
hinge to the centre of each of the portions of the splint on the outside. 
The zinc, from being soft, admits of being applied close to the limb, 
and can be fixed by means of strapping in the position in which the 
joint is ; a webbing-strap passed round the knee and over the con- 
necting piece of iron, will, by gradually tightening it, effectually 
straighten the limb." 

All forms and degrees of knock-knee may be successfully treated, 




Apparatus for knock-knee. 



OF THE HEAD AND NECK. 289 

as far as mechanical means will accomplish it, by the apparatus now 
described. There are cases where section of the biceps cruris will 
be required to insure a satisfactory result before the apparatus is 
applied. 

Loss of Function of the Ligaments of the Hip.— The capsular 
ligament of the hip-joint may become so relaxed in certain cases of 
children with feeble constitutions and relaxed habits of body, that the 
femur gains more motion than is compatible with steady and firm 
locomotion. The patient has a sensation of yielding at every step, as 
if he were walking upon some soft and yielding surface. 

The mechanical expedient for correcting this unpleasant condition 
of things consists in making pressure upon the trochanter major from 
behind, forwards and inwards — that is, to press the head of the femur 
into the acetabulum. This may be accomplished by means of a 
metallic lever jointed at the hip, terminating above beneath the 
axilla in a crutch, and below in a short arm reaching to the middle 
of the thigh ; this is connected to the body by a pelvic strap and a 
broad webbing-band surrounding the chest, while its lower end is 
secured to the thigh by a padded metallic strap. From beneath the 
joint a stem projects bearing a firm compress, regulated by a screw, 
to make the requisite degree of pressure over the trochanter. To 
prevent the apparatus slipping around the hips, an additional strap 
may be added, passing round the opposite thigh. 



CHAPTER III. 

APPAEATUS for remedying loss of symmetry of parts. 

SECTION I. 

apparatus for remedying loss of symmetry of the head and neck. 

Deformity of the ISTose. — In fracture of the nasal bones, this 
organ may be bent over to one side or the other so as to produce a 
painful deformity, and indeed in the majority of cases of such injuries 
more or less distortion remains either because patients do not apply 
to the surgeon timely enough to have the fracture promptly reduced, 
or because, in consequence of the tumefaction of the parts the nature 
of the injury remains undiscovered until the opportune time has fled 
to correct the oversight or mistake. But even in instances where the 
nose has been bent aside for some time, continuous pressure will re- 
dress the organ to some extent. This may be accomplished by means 
of a firm pad borne upon the end of a metallic stem, moving by a 
ratchet arrangement, and sustained in position by being connected 
with a padded metallic spring surrounding the forehead. By the aid 
of a key the pressure may be increased or diminished at pleasure upon 
that side of the nose towards which the bend has occurred. 
19 



290 APPAEATUS FOE EEMEDYING LOSS OF SYMMETEY 



Immobility of the Lowee Jaw. — Immobility of the lower jaw 
originates from preternatural contraction of the masseter and tempo- 
ralis muscles, the formation of cicatricial tissue in the form of bands, 
or the establishment of osseous union between the jaws, and produces 
a painful and serious deformity in the configuration and symmetrical 
proportion of the features of the face. When of long duration the 
chin projects beyond the upper jaw, the lower incisors grow to an in- 
ordinate length, assuming a decidedly carnivorous appearance. The 
most frequent cause of this deformity is the destructive effects of the 
excessive use of mercurials upon the lower jaw and the soft tissues 
connected with it. 

Treatment. — The mechanical treatment required in this disease con- 
sists in forcibly separating the jaws. 
Fig. 202. For this purpose the instrument of 

Scultetus (Fig. 202), constructed 
upon the principle of the screw 
and lever, was commonly employed 
by the late Dr. Mott. 

Dr. Gross, of Philadelphia, re- 
gards the instrument exhibited in 
the annexed sketch (Fig. 203) as 




Scultetus' lever for separating the jaws. 



Fig. 203. 




Lever for separating the jaws. 



Fig. 204. 



superior, as a mere lever, to that of 
Scultetus. It bears a close resem- 
blance to the instrument used by 
Pare, and figured in his work. 

For the same purpose Mr. Tamplin 
used an instrument fitting the teeth 
of the upper jaw, which acted as a ful- 
crum, and introduced over the teeth 
of the lower jaw small narrow blunt 
steel ho<3ks attached to the instrument 
by means of a screw ; with this he 
gradually forced the jaws asunder. 

An ingenious modification of this 
instrument (Fig. 204), and one much 
superior to it, has been devised by 
Mr. Bigg; it is composed of "two 
firm but thin rods of metal accurately 
modelled to the chin and articulated 
at the point where the lower jaw has 
its axis of motion. To each rod is fixed a horizontal metal lip, which, 




Bigg's apparatus for separating the jaws. 



OF THE HEAD AND NECK. 



291 



Fig. 205. 



having been first covered with India-rubber, is inserted between the 
lips. By means of two vertical screws, fixed at the angles of the lips, 
the rods can be separated from each other and the mouth gradually 
opened." 

Pkojection of the Chin. — Sometimes, after the first dentition, but 
especially after the second, in certain children, the lower jaw projects 
beyond the upper so as to cause an unpleasant prominence of the chin. 

Treatment. — The deformity may be corrected by bringing pressure 
to bear upon the chin by means of a sling bandage fastening over the 
occiput. An inclined plane made of gold or silver may be fastened 
to the lower teeth, sloping upwards towards the palate, which, when 
the jaws are brought together, forces the lower one backwards, and 
the upper one in the opposite direction. 

Distortion of the Lips from Burns. — The surgeon can accom- 
plish a good deal in preventing deformity of the lips, following burns, 
by placing those organs in favorable position during the contraction 
of the cicatricial tissue filling up the gaps left by the separation of the 
sloughs. The contraction, when unopposed, pulls the lips downwards, 
everts them, thus exposing the gums and teeth to view, and permitting 
the saliva to flow unobstructed from the mouth. 

Treatment. — In carrying out the mechanical treatment, the indica- 
tion is to make pressure upon the lips against the teeth and to raise 
the chin. This may be done by the following appliance (Fig. 205) : 
A metallic stem projects from the apex 
of a vertebral lever provided with 
pelvic straps and axillary supports; the 
stem is jointed so as to move antero-pos- 
teriorly, and bears at its top two curved 
arms fitted with a movable pad at their 
extremities, which is intended to make 
pressure upon the lips, while the counter 
pressure is effected by a concave, pad- 
ded disk, moved by a screw working 
through the stem above the point of 
attachment of the arms, acting against 
the occiput. 

Deformity of the Chin and Neck 
from Burns. — Deformity resulting 
from burns of the chin and neck is 
often considerable, the contracting 
inodular tissue dragging down the 
chin and lips to the chest, destroying 
the symmetry and impeding the per- 
formance of the functions of the parts so as to place the patient in the 
most lamentable plight. 

The most promising time for the mechanical treatment of such cases 
is during cicatrization, when the parts can be easily placed and held 
in any desirable position ; though some alleviation of the deformity 
may be brought about at later periods, or when the newly-formed 
tissues have already contracted. 




Apparatus to prevent deformity of the lips. 



292 APPAKATUS FOR REMEDYING LOSS OF SYMMETRY 



Fig. 206. 




The most complete control can be obtained over the head by the 
use of an appliance (Fig. 206) composed of a vertebral lever, axillary 
supports, and pelvic straps, to which is added a cervical stem with 

two articulations, to obtain motion, an- 
tero-posteriorly and laterally. From the 
apex of this stem two arms project, mov- 
ing vertically, by means of a joint, and 
capable of being opened or shut by simply 
turning a screw. The ends of the arms 
are furnished each with a short stem, 
padded at both of its extremities, and at 
right angles with it. These pads are 
intended to rest upon the temples and 
upper jaw, and to hold the head firmly 
in their grasp. 

Another form of instrument may be 
employed when the chin is mainly in- 
volved in the distortion. It consists of 
a cervical stem, fixed to a vertebral 
lever, as in the previous instrument, 
and having lateral and antero-posterior 
motion. To its apex are affixed curved, 
broad arms, grasping the occiput as far 
forward as the temples ; the point of one 
arm supports a vertical lever terminating 
in a chin rest. With this instrument it 
can readily be understood how both the head and chin may be placed 
in any desired position. 

Posterior Curvature of the Neck. — This deformity consists in 
the formation of a posterior curve in the lower cervical and upper 
dorsal vertebrae ; sometimes the curve involves all the vertebras to the 
last lumbar, constituting what has been called posterior curvature of 
the spine. Persons affected in the former manner present an appear- 
ance generally designated as round shoulder, or stoop. 

Posterior curvature of the neck occurs in young persons between 
10 and 16 years of age, and in both sexes. Its subjects are weakly, 
with health more or less impaired, soft flabby muscles, and growing 
rapidly. This condition of the system will be found to form the 
groundwork of the deformity, while its exciting causes are those 
employments requiring a person to stoop constantly, leaning over 
desks, &c. 

The patient at first can readily correct the mal-posture of the neck 
when directed so to do, but by degrees, if the case is neglected, the 
curve becomes permanent in consequence of the anterior edges of the 
intervertebral cartilages becoming somewhat atrophied from pressure, 
and the muscles adapting themselves to the altered position. 

This curve of the vertebrae necessarily causes the ribs to become 
more prominent, posteriorly raising the scapulae, and in this manner 
giving the shoulders the rounded outline observed in these cases ; at 
the same time the head and neck sink between the shoulders. 



Apparatus for preventing deformity after 
burns. 



OF THE HEAD AXD XECK. 293 

It is very important to make a careful diagnosis of this deformity 
from curvature produced by caries of the bodies of the vertebrae — 
angular curvature, as it is called. The main distinguishing points are, 
that in it ; the obliteration of the curve occurs when the patient is 
placed in the horizontal position upon his face, and the spinous pro- 
cesses form an uninterrupted line, features never observed in angular 
curvature. 

Treatment. — As the deformity is often associated with the strumous 
diathesis, the treatment will be directed to the removal of this consti- 
tutional vice, and the debilitated condition of the system. From what 
has been said concerning its pathology, the mechanism required to 
meet the indications of the case is readily conceived. A vertebral 
stem, with its upper extremity expanded and well padded to fit the 
shoulders, fastened to the body by shoulder-straps and a pelvic band. 
From the upper part of the dorsal plate a cervical stem projects, bear- 
ing at its upper end two curved levers, with broad and padded extre- 
mities to support the chin ; these move, by means of a ratchet screw, 
vertically and laterally. When this instrument is applied the shoulders 
are drawn back, and the spine and head supported efficiently. 

Axgular Cervical Curvature. — A disease of a much more 
serious character than the one just now considered is angular curva- 
ture of the spine. It consists most often in a dyscrasic condition of 
the solids and fluids of the body with a deposition of the matter of 
scrofulosis or tuberculosis into the bony tissue of the bodies of the 
vertebras with subsequent ulceration or caries of these parts. The 
most frequent seat of the disease is in the dorsal region, and eminently 
in the 2d, 3d, and 4th pieces, next in frequency in the lumbar region, 
and lastly in the cervical vertebrae. It is found to occur in all classes, 
though more frequently in the ill-fed, badly lodged denizens of alleys 
and lanes, and at all ages, yet more especially between 3 and 10 years, 
and in both sexes. 

When the disease occurs in the cervical region, it is accompanied 
with an angular projection of spinous processes of one or more ver- 
tebras, which distinguishes it from posterior cervical curvature. 

Treatment. — In these cases, besides the constitutional and local treat- 
ment necessary, it is indispensable to support the head and neck by a 
suitable apparatus, lest in some unguarded movement, the diseased 
vertebrae cave in and crush the spinal cord. 

Mr. Bishop, of London, has recommended a contrivance (Fig. 207) 
which will answer every purpose. It is simply a broad metallic plate, 
fitted to the spine, and well padded, having two arms affixed to its 
upper end, in which the occiput is intended to repose. The two pieces 
are connected by a joint which permits the head to move in every direc- 
tion, except laterally, and in forced extension. The instrument is 
fastened to the person by shoulder-straps, thoracic and pelvic bands. 
In this manner the cervical vertebrae are securely held, and all motion 
of the head in perilous directions checked. 

To answer the same purpose, a gutta-percha shield (Fig. 208), 
moulded to the back and posterior part of the neck, with an occipital 



294 APPARATUS FOR REMEDYING LOSS OF SYMMETRY 



rest, may be prepared and attached to the body by a broad thoracic 
band and shoulder-straps. 

These two forms of appliances are well adapted to children, who 
may be moved about securely, without fear of any sudden pressure 
upon the cord. 



Fig. 207. 



Fig. 208. 





Bishop's apparatus for caries of the vertebrae. Gutta-percha shield for caries of the vertebrae. 

For the purpose of permitting a patient to stir about for the benefit 
of fresh air ; without increasing the spine mischief, Mr. Bigg has 

designed an instrument (Fig. 209), 
composed of a vertebral lever and 
axillary rest, with a stem projecting 
from its upper end, bearing two 
padded arm-like processes, intended 
to grasp the head, from the occiput 
to the temporal regions, and hold 
it firmly ; the arms can be elevated 
or depressed, and the space between 
them increased or diminished. 

Torticollis, or Wry -Neck. 
— This deformity consists in the 
permanent contraction of the cer- 
vical muscles, principally the ster- 
no-cleido-mastoid, which draw the 
occiput towards the shoulder of the 
shortened muscle, while the face is 
turned in a corresponding degree 
in an opposite direction. The causes 
are, anything that destroys the bal- 
ance of the muscular force upon 
the two sides of the neck, such as 
, the stronger contraction of one of 

Bigg s apparatus for securing immovability of o 

the head, in caries of the cervical vertebrae. the StemO-cleido-mastOlQ mUSCleS, 




OF THE HEAD AND XECK, 



295 



while the other retains its normal activity ; or one muscle may become 
paralyzed, thus destroying the natural muscular antagonism. Eheu- 
matic or other inflammation of the parts will produce the same result. 

The disease is rarely congenital, and is observed most frequently 
between the third and tenth year of age. 

Treatment. — Simple mechanical treatment will succeed, in mild 
cases, in restoring the head to its natural position ; the severer ones 
will require the preliminary use of the knife to divide the tendon of 
the contracted muscle before the mechanical means are resorted to. 

An apparatus sometimes employed is that of Prof. Jorg(Fig. 210), 
composed of a leather corset, and a fillet to encircle the head; these 
are connected by a small steel bar, moved by a ratchet arrangement 
under the control of a key. 



Fig. 210. 



Fig. 211. 




Professor Jbrg's apparatus for torticollis. 



Bonnet's apparatus for torticollis. 



Bonnet invented a much more ingenious and efficient apparatus, 
(Fig. 211) that does not embrace the chest and impede respiration. It 
consists of a plate of gutta-percha, modelled to the back and shoulders, 
to which it is fastened by straps passing beneath the axillas and 
around the waist. From the back part of this shield a metallic rod 
ascends, curving over the head, and capable of motion antero-poste- 
riorly and laterally, by means of a ratchet-wheel. Through the top of 
the rod a screw works, supporting two padded arms, to grasp the sides 
of the head, and when in place they are secured by a strap passing 
beneath the chin. 

By this arrangement the head may be held in any desired position. 



296 APPAKATUS FOR REMEDYING LOSS OF SYMMETRY 



Fig. 212. 



An efficient contrivance was invented by Mr. Bigg, of London 
(Fig. 212), who describes it as " consisting of a padded pelvic band, to 
which is attached a vertebral stem with hori- 
zontal arm-pieces. At the upper extremity of 
the vertebral stem a neck-lever is fixed, to be 
attached or detached at will. This lever is 
formed in a peculiar fashion. It passes around 
the head, and rests, by its outer extremity, 
against the temporal bone, on the side towards 
which the head is deflected. On the opposite 
side of the head a horizontal lever is fixed, also 
springing from the vertebral stem, and resting 
against the lower jaw. The temporal lever has a 
vertical axis, moved by a ratchet-joint, upon turn- 
ing which the head is gently pressed in a hori- 
zontal direction. The lower-jaw lever also acts 
horizontally, but in a different plane." He re- 
marks : " That by the conjoint action of these 
two levers the contracted sterno-mastoideus 
muscle is extended, the head restored to an 
erect position, and the chin brought into the 
mesial line of the body. From the position of 
the lever, displacement of the head, when the 
instrument is properly applied, is impossible, 
and by a little modification of the dress and 
arrangement of the hair the mechanism may 
be almost entirely concealed." 

A greater range of motion of the arms, in 
which the head is grasped, is secured by the apparatus seen in Fig. 
213, which, besides being enabled to change the position by the connec- 




Bigg's apparatus for tor- 
ticollis. 



Fig. 213. 



Fig. 214. 



Fis?. 215. 




Apparatus for torticollis. 




Same applied. 




Apparatus for torticollis. 



tion of their rods with the vertebral stem, also possess centres of motion 
at their apices; the extent of motion being regulated by thumb-screws. 

The mode of applying the apparatus is shown in Fig. 214. 

Of all the forms of apparatus for the treatment of torticollis, the 
one seen in Fig. 215 is preferred by me. It consists of a pelvic strap 



OF THE TRUNK. 297 

and a vertebral stem, reaching to the occiput, and bearing padded me- 
tallic arms to grasp the head firmly ; the arms are perforated upon 
both sides by oval openings, which leave the ears uncovered ; to enable 
the arms to hold the head more securely, a chin and a frontal strap 
are fastened to them. 

To give stability to the vertebral lever two axillary supports and 
shoulder-straps are attached to it. 

The vertebral lever has, at its upper part, two centres of motion, 
one antero-posterior, and the other lateral, controlled by a key, which 
enable the surgeon to manage the movements of the head in the most 
perfect manner. 

Where it is practicable, it is always desirable, in using wry-neck 
apparatus, that they take their point oVappui upon the hips, which 
confers upon them greater stability and power of holding the head 
firmly. If, from any cause, this arrangement cannot be pursued, Bon- 
net has suggested an apparatus to meet the emergency. It is con- 
structed of a broad metallic plate, fitting the shoulders, and connected 
to them by straps passing under the axillas and across the breast. 
Upon each side of the collar a vertical bar is soldered, supporting 
at its apex a horizontal screw armed with a concave padded plate. 
One plate is intended to press against the lower jaw upon one side, 
and the other plate upon the cheek-bone on the opposite side. 

With the same view Mr. Bigg suggests the use of a better instru- 
ment, consisting of a curved piece of steel resting upon the shoulder 
towards which the head is drawn, and retained in place by padded 
straps which pass under the shoulders. From the plate spring two 
levers with padded extremities. These levers are so arranged that 
one rests on the parietal region of the contracted side, and the other 
on the mastoid process of the opposite side, their action being governed 
and directed by ratchet screws. 

SECTION II. 

APPARATUS FOR REMEDYING LOSS OF SYMMETRY OF THE TRUNK. 

Lateral Curvature of Spine. — The deformity now under con- 
sideration is unconnected with ulcerative diseases of the vertebras or 
caries, as is the case in angular curvature, except in extremely rare 
cases. The disease in the great majority of instances is observed among 
girls in the upper classes of society, between the ages of twelve and 
eighteen years. 

Symptoms. — The disease often begins insidiously, making decided 
progress before the parents of the patient are fully aware of the seri- 
ousness of the condition of their daughter ; perhaps, on inquiry, the 
physician will find some time to have elapsed since the first deviation 
in form was observed, appearing to be an "outgrowing" of the shoulder 
and corresponding breast. The patient's general health will sometimes 
remain undisturbed antecedent to the spinal deflection, though most 
often it will be found to have been more or less deranged. The appe- 
tite fails, the bowels become constipated, and the nutrition defective, 



298 APPARATUS FOR REMEDYING LOSS OF SYMMETRY 



so that the patient loses flesh, is easily fatigued, and constantly seeks 
rest in a horizontal position. 

In some instances, along with the feeling of great weariness, there 
will be more or less pain experienced in the back ; sometimes the pain 
is continuous, and referred to the left side below the ribs. 

In cases that have made some progress, the spinal column will be 
seen to have curved in the dorsal region to the right, and in the lum- 
bar to the left ; this is by far the most common condition, though the 
reverse may sometimes be observed in boys, and it then always depends 
upon the inordinate exercise of the muscles of one side or upon the main- 
tenance of the body in awkward positions. The dorsal curve carries 
with it the ribs, and pushes those upon the right side backwards, 
forming a protuberance beneath the scapula, which then presents an 
unnatural prominence while the corresponding shoulder will be 
found elevated and projecting. The ribs connected with the concavity 
of the curve are flattened and the corresponding shoulder depressed. 
The formation of the lumbar curve causes a disproportionate promi- 
nence of the left hip, while the right one sinks in a corresponding 
These changes are well shown in Fig. 216. 



degree 



Fig. 216. 



Fig. 217. 





External appearances of lateral curvature. 

If a third curve, formed by the upper dorsal and lower cervical, 
exists, as is sometimes seen (Fig. 217), the external characteristics of 
the disease now mentioned will be modified to some extent. The 
side of the chest upon the convexity of the dorsal curve becomes 
flattened, the corresponding side of the neck falls in, while the oppo- 
site side of the neck and chest appears much fuller, and is accompanied 
with an elevation of the shoulder ; yet, though its scapula is higher, 
it does not project so much as the scapula upon the dorsal curvature. 



OF THE TRUNK. 



299 



In aggravated cases besides these mesial curvatures there is added 
another — helical curvature — formed by the bodies of the vertebras 
rotating upon their own axes in the direction of the concavity of the 
curvature. 

The shape and capacity of the chest are altered in consequence of the 
ribs becoming elongated, flattened, and twisted, thrusting the sternum 
and costal cartilages forwards, while they are unnaturally approxi- 
mated to the pelvis. The spine is decreased in height, the muscles and 
ligaments upon its convexities stretched, and if the deformity results 
from excessive use of the limb upon one side they will be found more 
vigorous than their congeners, while those located in the concavities 
of curvature are preternaturally contracted, atrophied, and rigid. 
These changes in the bones of the spine and the ribs are seen in the 
annexed sketches. 



Fig. 218. 



Fig. 219. 




Appearances of the bones in lateral curvature of spine; front and back views. 

The causes of lateral curvature are numerous, some of the principal 
are : Unequal muscular action, by which one set of muscles acts more 
vigorously upon the spine than those that counterbalance them, thus 
drawing it to one side; this is seen in blacksmiths, dragoons, and 
those persons who use one arm more than the other. The same result 
will follow if the equilibrium is destroyed by the muscles upon one 
side of the spine becoming debilitated or paralyzed from any cause, 
the stronger muscles will drag the spine towards their side. Any- 
thing that mars the uniform growth and development of the muscles 
will be likely to cause lateral curvature; we see this exemplified in 



300 APPAEATUS FOR REMEDYING LOSS OF SYMMETRY 

females who indulge in the pernicious habit of tight lacing, "the 
common effect of which practice is obstruction in the lungs, from 
their not having sufficient room to play, which, besides tainting the 
breath, cuts off numbers of young women in the very bloom of life. 
But nature has shown her resentment of this practice, by rendering 
above half the women of fashion deformed in some degree or other." 

The fatigue of the spinal muscles produced by sitting with the back 
unsupported, for lengthy periods ; habitually assuming awkward 
positions in standing, sitting, or lying will also induce it. Obliquity of 
the pelvis from inequality of the length of the lower extremities, the 
wooden pin, and other badly constructed artificial limbs are fruitful 
sources of spinal distortion. 

Lastly, rickets will often be found to predispose to this deformity. 

Treatment. — The successful treatment of lateral curvature requires 
on the part of the patient determination of will and a faithful ad- 
herence to the directions of the surgeon, inasmuch as the benefit to 
be obtained is not a question of days, but one of months. In the 
early stage of the disease, it may generally be overcome and a favor- 
able issue brought about; later, when the deformity has become firmly 
established, the most that can be done is to ameliorate the patient's 
condition. Under the latter circumstances, the person should be 
promptly informed that two years of patient treatment, at least, will 
be required to obtain any decided and permanent improvement. 

The first object should be to investigate carefully the cause of the 
deformity; perhaps the removal of this will arrest the progress of 
the spinal deflexion at once : for instance, inequality of length of the 
legs, from fractures, hip or knee disease, &c, must be corrected by the 
use of proper mechanical appliances, and the spine, by its own elas- 
ticity, will restore, in a short time, symmetry to the form. 

Constitutional treatment is indispensable. Efforts should be made 
to establish the general health; to correct, as far as possible, the 
derangements of the stomach, bowels, and uterus so often observed 
in these cases; and to surround the patient by favorable hygienic 
conditions. 

As to the mechanical treatment, surgeons have differed in opinion. 
Mr. Skey directs that the patient should be placed in the horizontal 
position to remove "the cause of the entire evil, viz., the superincum- 
bent weight." He regards the horizontal position as quite compatible 
with health, with education, and with the enjoyment of life. His plan 
is to select a narrow bedstead about three feet in width, running on 
large wooden castors, by means of which it may be wheeled about in 
any direction. Upon this is placed a well-made wool mattress. When 
the patient is stretched upon this, he endeavors to unfold the spinal 
curves by making extension from the two extremities of the spinal 
column ; that above by a belt applied around the chin and occiput, 
attached to a cord passing over a pulley let into the head-board of the 
bed, and supporting a weight of from ten to twenty pounds. That 
below is attached by a broad belt around the pelvis, and including 
the crista of each ilium. To the sides of this belt are two straps, that 
unite below, and to them may be attached a weight of from twenty to 



OF THE TRUNK 



301 



thirty pounds. This extension may be worn sixteen hours out of the 
twenty-four of each day and night. To restore the projecting ribs to 
their natural form and relation, he employs a large pad covered with 
soft leather, arched to fit the projecting curve, and borne by a screw 
passing through an upright fastened to the bedstead ; counter-pressure 
is established by two similar but smaller pads acting upon the oppo- 
site hip and back of the neck. The large pad should be made so as 
to press, not in the transverse or horizontal direction, but in that 
obliquely forwards ; the smaller pads may press horizontally. This 
lateral pressure should be maintained as firmly as the patient can bear, 
for much of the success of the treatment depends on its efficacy and 
permanence. 

To enlarge the capacity of the diminished half of the chest, he 
endeavors, by compressing the abdomen with a thick and soft pad of 
lint or cotton-wool, or a pad containing bran or horse-hair, and a 
broad bandage, to control the action of the diaphragm, and throw the 
duty of inspiration on the intercostal muscles, which are in a reduced 
and weakened condition. Mr. Skey remarks, in relation to this prin- 
ciple of treatment, that " it should be persisted in till observation of 
the back, to be occasionally made, obtain conclusive evidence of posi- 
tive improvement. JSTor, indeed, should it even then be desisted from, 
but rather modified as we approach, at the expiration of from eighteen 
months to two years, or possibly more, the period for entering on the 
second stage of the treatment — gymnastic exercises." 

Similar to this couch, but gotten up with more elegance of me- 
chanism, is a contrivance represented in Fig. 220, and employed by 

Fig. 220. 




Eecumbent couch for lateral curvature. 

some of the German surgeons. It consists of three sections, the upper 
one corresponding to the cervical, the middle to the dorsal, and the 
third section to the lumbar curvature. To the upper end of the couch, 
a padded receptacle for the head is fixed, carrying a chin pad and 
strap. A padded band for the pelvis is connected by two lateral 
straps to a strong metallic spring secured to the foot of the couch. 
These are the mechanical provisions for permanent extension. To 
compress the dorsal curvatures, a broad pad is attached to the right 
edge of the plane ; and two smaller ones to the left edge, to make 
counter-pressure upon the cervical and lumbar curves. By means of 



302 APPAKATUS FOR REMEDYING LOSS OF SYMMETRY 



a screw, the upper and middle sections are separated upon their left 
edge only, while a similar motion is impressed upon the middle and 
lower sections at the right edge. 

The mechanical principle of the couch' is evident: the arcs of the 
spine are extended from their extremities, while the pads exercise 
pressure upon their apices ; the hinge movements of the sections act 
upon the column in opposite directions to its inflections. 

An ingenious couch (Fig. 121), invented by Mr. Bigg, does not re- 
strain the movements of the patient to the same extent as the two 
described above, and will be found useful in cases of moderate curva- 
ture, or in nervous persons as preliminary to the employment of more 
efficient couches requiring greater immobility of the body. 

Fig. 221. 




Bigg's couch for lateral curvature. 

He describes it in the following manner : " The couch consists of a 
well-padded surface, having a rest for the head, which can be moved 
obliquely upwards by means of an elastic cord fixed to the upper rail 
of the plane." 

"At the lower edge of the plane another rail is arranged for the 
attachment of two elastic bands belonging to a padded belt, which is 
fastened round the hips. Another rail is arranged at the side corres- 
ponding with the dorsal curve, and a fourth rail is fixed at the lateral 
edge of the plane answering to the lumbar curve. To both these rails 
soft webbing bands are fastened by elastic cords, and these webbing 
bands pass in antagonistic directions over the arcs of dorsal and lum- 
bar deflections." 

The apparatus contrived by Yalerius, a mechanician of Paris, called 
the " corset-lit," is a very ingenious contrivance, and answers all the 
indications of treatment of lateral curvature as fully as any of the 
couches hitherto brought to the notice of the medical profession. 

The mechanism consists of a padded model or mould of the poste- 
rior and lateral planes of the body divided into three sections, the first 
to embrace the back and chest, the second the loins, and the third sec- 



OF THE TRUNK. 



303 



tion to inclose the hips ; these are susceptible of vertical and lateral 
movements by means of screw power, and may be placed at any angle 
that may be deemed, by the surgeon, the most expedient for the case 
under treatment. The head is secured in a padded support resembling 
somewhat the back part of a casque, and capable of being varied at 
any angle, while the body is rendered immovable by shoulder and 
pelvic straps. The frame itself is supported upon a board by means 
of straps. 

Some persons have deemed it necessary to make extension only in 
the recumbent posture without lateral compression. This was the 
practice of Hippocrates, who established as points of extension the 
shoulders and hips of the patient. In France most of the couches are 
arranged with the upper extending cords acting upon the head. Of 
this sort is the one seen in Fig. 222, and employed by Dr. Maisonabe. 

Fig. 222. 




Maisonabe's couch for lateral curvature. 

Mr. Tamplin, Erichsen, and others believe that, except in altogether 
exceptional cases, continuous treatment in the recumbent posture is 
pernicious, and, therefore, if patients can get around with any degree 
of comfort, it is the most judicious plan to employ some form of spinal 
supporter, permitting them to go out in the open air, and have recourse 
to some kind of gymnastic exercise in order to strengthen the serrati, 
rhomboidei, and the erector muscles of the spine. 

These instruments are of two classes. 1st. Those that remove the 
weight of the head and upper extremities from the spine, and make 
lateral pressure upon it in opposite directions. 2d. Those that simply 
remove the weight without making the pressure. 

From what we have already stated concerning the mechanism of 
lateral curvature — that usually we find two curves formed, one in the 
dorsal region towards the right side, and the other or compensative 
curve in the loins looking to the left side, the vertebras, as the disease 
advances, rotating always in the direction of the concavity of curvature 
— it can readily be gathered that those instruments must be most efficient 
that oppose these displacements, by the exercise of an antagonistic force, 
with appropriate levers and pads. Those belonging to the first class 
are most esteemed by surgeons in the treatment of lateral curvature; 
some of them exercise lateral force in opposite directions simply, while 
others have a rotatory action. In their construction provision is also 



304 APPAEATUS FOR REMEDYING LOSS OF SYMMETRY 

sometimes made to elevate the depressed shoulder, or to depress the 
elevated one. 

The simplest form of a spine supporter, exercising lateral pressure, 
is a simple corset which transfers some of the weight of the upper ex- 
tremities to the pelvis, but has at the same time the insuperable ob- 
jection of compressing the chest, and impeding the development of 
muscular energy. Therefore it should be banished from use, particu- 
larly as there are other apparatus more efficient without these dis- 
advantages involved in their construction. 

A modification of the corset is seen in Fig. 223. Two lateral 
crutch-form supports and a vertebral lever are connected with the 
corset, the latter bearing at its apex a broad webbing band which 
crosses over the dorsal convexity, then passes in front of the corset, and 
is finally attached by means of a buckle to an arm projecting from 
the base of the lever. 



Fig. 223. 



Fig. 224. 





Apparatus for lateral curvature. 



Tavernier's apparatus for lateral curvature. 



Mr. Tamplin found Tavernier's lever-belt (Fig. 224) an excellent 
instrument in any slight case of curvature, which it promptly cured. 
Mr. Erichsen says that by this contrivance alone, properly and care- 
fully adjusted to the condition of the deformity, many patients may 
be treated without the necessity of any confinement whatever. It 
consists, as seen in the wood-cut annexed, of a well-fitted pelvic belt, 
bearing a vertebral lever, having attached to its apex a triangular 
band of webbing, which is intended to pass over and compress the 
dorsal curvature, and to fasten by its apex to the point of a short stem 



OF THE" TRUNK. 



305 



attached to the pelvic belt. To prevent the apparatus tilting or slipping 
up, a thigh-strap is sometimes attached, encircling the left hip. 

In severe cases of curvature, Mr. Tamplin found another form of 
supporter preferable. It consists, as seen in the sketch (Fig. 225), of a 

Fig. 225. 




Tamplin's apparatus for lateral curvature, 



band which encircles the pelvis, having a vertebral stem attached 
behind, at the upper portion of which is a movable pad, so made that 
it adapts itself to the projecting ribs, and with the screw the pressure 
can be regulated according to circumstances; beneath is an arm, 
which extends to the opposite side of the band, and which regulates 
the position of the vertebral stem, without causing the instrument to 
be displaced to any extent, by means of the screw presented in the 
diagram. 

The apparatus of Mr. Lonsdale is similar to that of Tavernier; 
there is added a crutch support, which sustains the depressed shoulder 
and obviates the tilting of the pelvic belt. It will be seen that 
these forms of instruments act upon the dorsal curve only of the 
spine, leaving the lumbar curve unsupported, while the counter- 
pressure comes upon the left hip through the pelvic strap. To carry 
out fully the mechanical requirements demanded in lateral curvature, 
it should be the object of the surgeon to bring pressure upon the 
apices of the arcs of curvature, by two lateral arms projecting from 
20 



306 APPARATUS FOR REMEDYING LOSS OF SYMMETRY 



a vertebral lever, supported by a padded pelvic band, to expand the 
curves ; and in those cases where rotation of the vertebrae has taken 
place, to bring pressure upon the ribs by two opposite parallel forces. 

Fig. 226. 




Lonsdale's apparatus for lateral curvature. 

An instrument partially based upon this principle is much employed 
in this country. It consists of pelvic straps, to which a vertebral stem 
is attached, bearing at its sides two padded elastic plates to press upon 
the dorsal and lumbar curves in opposite directions ; and at its top two 
horizontal arms projecting beneath the axillas, movable vertically and 
obliquely, by which the depressed shoulder may be elevated. 

Mr. Bigg, of London, to secure these advantages, has invented the 
instrument shown in the annexed woodcut (Fig. 227), which has for 
its object pressure upon the curves in opposite directions, and rota- 
tive action upon the twisted vertebrae and 
Fi g 227. ribs. He thus describes it : "It consists of 

a pelvic band sustaining two lateral up- 
rights and a vertebral stem which carries a 
shoulder-plate. At the base of the back 
lever, where it joins the pelvic band, two 
centres of movement are placed, one (a) 
acting anteriorly, the other (b) in a lateral 
direction. Thus, on moving the former, 
pressure of the plate forwards against the 
shoulder is caused, and on moving the lat- 
ter, lateral pressure against the ribs. The 
plate itself also has two centres of move- 
ment ; one (c) corresponding with the hori- 
zontal rotation of the ribs on the spine, and 

Bigg s apparatus for lateral curva- . i /■ \ • i -> • • i 

ture. the other (d) moving the plate in a vertical 




OF THE TRUNK, 



307 



Fig. 228. 



direction around its centre of attachment. By means of the hori- 
zontal shoulder movement (c) it was sought to act upon and re-rotate 
the ribs in an anterior direction. A controlling pressure was exer- 
cised upon the curvature by the movement (b) at the base of the 
vertebral lever. The shoulder itself was attempted to be depressed 
by the action of the vertical axis (d) in the shoulder-plate." As 
there was no counter pressure to the force exercised by the plate (d), 
little rotative action could have been expected, and it was to remedy 
this that he attached to the instrument subsequently, when the defect 
was observed, a padded plate, to rest against the antero-lateral surface 
of the thorax. 

A very efficient supporter (Fig. 228), in cases of moderate lateral 
curvature, was much employed by Sir 
B. Brodie, and invented by a London 
mechanician; in it there is an arrange- 
ment provided for depressing the elevated 
shoulder. It is constructed with a pelvic 
band and hip-straps supporting two late- 
ral crutch-like arms to support the shoul- 
ders, and a vertebral stem connected with 
the lateral crutch by a metallic rod at its 
apex. Upon the right shoulder there is 
a cap connected by a band to the pelvic 
belt, with a view to depress the former. 
Pressure is made upon the dorsal curve 
by a broad padded lacing-belt extending 
between the vertebral lever and the risrht 
crutch. The lumbar curve is acted upon 
by a pad and strap crossing the left hip 
obliquely. 




Apparatus for lateral curvature. 



It has been proposed, and the 
principle has been carried out 
in a number of appliances for 
rectifying spinal curvature, to 
substitute the pressure of elastic 
cords for that of metallic plates 
moved by levers, ratchet-cen- 
tres, and screws. This plan 
is adopted in the contrivances 
of Chelius, Joerge, and Du- 
chenne. A sketch of the in- 
strument of the latter is seen in 
the drawing (Fig. 229). It con- 
sists of a broad pelvic belt (c) 
supporting a vertebral lever (d) 
movable laterally at the point 
where the two parts connect. At 
the apex of the back stem a lever 
belt (a) is attached which passes 
over the dorsal curve to be 



Fig. 229. 




Ducheune's apparatus for lateral curvature. 



308 APPARATUS FOR REMEDYING LOSS OF SYMMETRY 



fastened in front. By means of elastic straps (k) extending between the 
vertebral lever and pelvic belt the former is drawn over towards the 
side of the convexity of lumbar curvature, and the lever-strap thus 
pressed firmly against the dorsal curve. A crutch support passes also 
from the pelvic belt beneath the axilla of the lower shoulder. 

A skilled mechanician of this city, Mr. Kolbe, has improved the 
apparatus of Duchenne somewhat by changing the attachment of the 
elastic straps from the pelvic belt to the lateral crutch (Fig. 230), so 
that they act to a better mechanical advantage ; greater firmness is 
also conferred upon it by the introduction into the pelvic belt of two 
oval metallic supports bent to fit the hip at each side. 



Fig. 230. 



Fig. 231. 





Apparatus for lateral curvature. 

The second class of spinal supporters act by simply removing the 
weight of the head and upper extremities from the spine and trans- 
ferring it to the hips. One of the simplest and oldest of these forms 
is seen in Fig. 231. It is prepared by fitting to the hips a well-padded 
belt, supporting two lateral crutches for supporting the shoulders, 
connected together by broad thoracic bands. This is an efficient con- 
trivance, and will, perhaps, serve every purpose that any of the instru- 
ments of this class are capable of. 

Bonnet and a good many of the French surgeons employ padded 
shields of the exact contour of the posterior surface of the body, 
fastening them by means of thoracic and abdominal straps. They 
are expensive, rather heavy, and more fatiguing to patients than the 
previously described apparatus. 

In rare cases, as has already been stated, instead of the two or three 
curves usually seen in this deformity, the spine presents a single 
dorsal curve to either one side or the other. The shoulder and hip 
upon the side corresponding with the concavity are more or less 
approximated, while those upon the opposite side are separated in a 
corresponding degree and more prominent. 

The mechanical apparatus required in single lateral curvature, 
when of moderate severity, may be constructed upon the principle of 
the apparatus already described, or the simple appliance sketched 
below (Fig. 232) will answer very well. 



OF THE TRUNK. 



309 



Fig. 232. 



Fig. 233. 





Apparatus for single curvature of the spine. 



Appearance of posterior curvature. 



Posterior Curvature of the Spine. — We have already con- 
sidered posterior curvature as it affects the cervical vertebras, and 
therefore it remains for us to describe this deformity as it occurs in 
the dorsal region. When the back is viewed from behind one con- 
tinuous and uniform curve will be seen extending from the lower 
cervical to the last lumbar, as shown in Fig. 233. 

This condition is most frequently met with in young children, and 
infants under twelve months of age. The patients presenting the de- 
formity will be found suffering more or less from general debility and 
relaxation of the muscles and ligaments, so that the weight of the 
head and upper extremities causes the spinal column to sink and curve 
posteriorly. If the person is placed in a sitting posture, the trunk 
will incline forwards from sheer inability of the muscles to sustain the 
spine erect. Under the head of angular curvature of the neck the 
diagnostic differences of this deformity and posterior curvature have 
been pointed out, and they need not be repeated here. 

The medical treatment in this deformity should be directed to the 
restoration of the general health, the re-establishment of muscular 
tonicity, and the correction of any scrofulous or other constitutional 
taint by tonics, nourishing food (eggs, milk), &c. In infants the hori- 
zontal position will generally suffice to correct the deformity in a few 
weeks. In older persons, and in those cases where the disease has 
made greater progress, the persistent employment of mechanical means 
is indispensable. 

One of the best forms of instrument for posterior curvature is seen 
in Fig. 237, at page 314; omitting the head-piece according to the cir- 



310 APPARATUS FOE REMEDYING LOSS OF SYMMETRY 



cu instances of the case. The pads should be placed below the arc of 
curvature. 

Mr. Tamplin recommends an apparatus (Fig. 234) somewhat similar, 
by which, at the same time that the weight is taken off the upper por- 

Fig. 234. 




Tamplin's apparatus for posterior curvature. 

tions of the spinal column, a continued pressure can be kept upon the 
prominent portion of the curve by the back-board attached, and the 
shoulders held back by the straps. The head-piece can be removed 
at will. 

Angular Curvature (Fig. 235). — This deformity results from 
caries of the bodies of the vertebrae. It is most frequently met with in 
children, male and female alike, between the ages of three and twelve 
years, though it has been observed both earlier and later than these 
periods. Its more common subjects are those badly-clothed and fed 
persons living in dark and ill- ventilated hovels in the narrow streets 
and alleys of our large cities. The disease depends often upon a scro- 
fulous or tuberculous diathesis, and is then attended with deposition of 
characteristic tuberculous matter in the osseous tissue and interverte- 



OF THE TRUNK. 



311 



bral cartilages of the bodies of the vertebrae. In other instances it 
proceeds from common inflammation of these parts, set up, in many 
cases, perhaps, by exterior violence inflicted upon the spine. 

Symptoms. — During the formative stage of the disease the patient 
will display a general derangement of the health ; pain in the back, 
at first slight, will generally be complained of, and, as the disease 
progresses, will become more severe. It is aggravated by any rude 
or unexpected movement of the body, as in making a false step or 
tripping. From the irritation of the spinal cord there will result more 
or less derangement of innervation of the parts below ; the muscles of 
the legs will contract irregularly, or other perversions of sensation or 
motion will present themselves. The patient is disinclined to take 
exercise, from the sensation of weariness or weakness which he feels, 
and he habitually seeks repose in a horizontal position. 

As the ulceration and destruction of the vertebral substance pro- 
ceed, the above symptoms become more pronounced, and others of a 
more serious character are added. The extremities become cold and 
sluggish, and refuse to respond promptly to the stimulus of the will ; 
the appetite entirely fails ; the secretions are unhealthy ; the respira- 
tion embarrassed; and the patient finally becomes emaciated, and 
loses control over the lower limbs, bladder, and rectum. It is during 
this time that the most charac- 
teristic feature of the disease is Fi g- 235 - 
developed, namely, an angular 
curvature at some part of the 
spine, projecting posteriorly. It 
is formed by the spinous pro- 
cesses, and, as its name imports, 
is abrupt or pointed, a circum- 
stance which affords the surgeon 
an important diagnostic mark to 
distinguish this disease from pos- 
terior curvature in which these 
processes form an uninterrupted 
curved line. 

The destruction of the bodies 
of the vertebrae, upon which the 
angularity depends, is often ac- 
companied with the formation of 
considerable purulent accumula- 
tions at the point where the dis- 
eased action is going on, and the 
matter generally makes its ap- 
pearance externally either at the 
loins or groin, according to the position of the abscess. 

By the continual formation and discharge of pus the system is fur- 
ther enfeebled, and in such cases the patients are commonly worn out 
by constant suffering, and finally carried off by hectic and exhaustion. 

Treatment. — The medical treatment in angular curvature consists 
in the employment of tonics, alteratives, and stimulants — in fact, those 




Appearance of aDgular curvature. 



312 APPARATUS FOR REMEDYING LOSS OF SYMMETRY 

remedies appropriate to remove the constitutional taint of scrofula or 
tuberculosis; counter-irritation, by establishing an issue upon the side 
of the spine, with the actual cautery, will also be of immense service. 

While the caries is progressing, all mechanical appliances should 
be abstained from, and the patient be placed in the horizontal pos- 
ture; the prone being thought by some far more suitable for relieving 
pressure upon the spine and congestion of the parts than the supine. 
In regard to this point, Mr. Tamplin observes : " The plan I usually 
adopt is the following : to request that the parents should obtain a 
board somewhat wider and larger than the patient ; let a horse-hair 
mattress be placed upon it, and let two circular holes be made in it at 
the point corresponding with the axilla, in which can be inserted a 
couple of plugs (one for each side), when the patient is in the inclined 
position, to prevent them from slipping down. With this simple con- 
trivance, which is within the reach of all, from the facility of obtaining 
it, a child may be kept at rest, the disease protected from pressure, 
and the angle relieved, or, at all events, any increase of it effectually 
prevented ; while, at the same time, it is the greatest possible source 
of comfort to the patients, who, instead of becoming fretful and irri- 
table, with the health suffering as a consequence, as might be antici- 
pated from the confinement, actually improve in health, and are most 
completely relieved from pain." 

Mr. Erichsen prefers the couch of the late Mr. Yerral, of London. 
In the construction of this couch of two inclined planes joined at an 
obtuse angle, he supposes that the twofold object of removing the 
weight of the upper part of the body from the spine, and slight ex- 
tension of the spine by the weight of the pelvis and lower extremities 
upon the inclined plane, is obtained. On the other hand, Mr. Bishop 
takes a different view of the matter, for he employs the triple-inclined 
plane of Earle, and adopts a recumbent position, occasionally changing 
it from the back to the side. He says that the result of a number of 
observations is this — namely, that, in cases of curvatures of the spine 
arising from disease and absorption of the bone, the distortions do 
not increase while the body is kept in horizontal, supine, and lateral 
positions, but they do increase when the body is allowed to move and 
be erect; and that, moreover, when patients are confined to the prone 
position, so far as his experience goes, the curve of the spine is pro- 
gressive, for which there are obvious mechanical reasons. For instance, 
in all cases, both of diseased bone and curvature, the superincumbent 
pressure cannot be wholly withdrawn in any oblique position ; and 
where the curvature is in a plane or planes intermediate between the 
mesial and transverse, as generally happens, the deformity may often 
be increased by the tendency of the unsupported curved position 
towards the transverse plane. 

When the patient has been kept in a horizontal position until an- 
chylosis of the diseased vertebrae has taken place, which will require 
at least eighteen months, he may be permitted to go about with the 
spine carefully supported by a proper mechanical apparatus. 

Mr. Tamplin employed for this purpose an instrument seen in Fig. 
236, consisting of a band which encircles the pelvis, having attached 



OF THE TRUNK. 



313 



two crutches, one on each side, to support the shoulders, the crutches 
consisting of a male and female screw, which enables the surgeon to 

Fig. 236. 




Tamplin's apparatus for angular curvature. 

increase their length, provided relief is obtained, as the child grows. 
A broad flannel band should be passed round the crutch on one or 
other side, and over the projecting vertebra, then round the opposite 
crutch back again to the commencement of the band, and there united ; 
by this means an effectual support is given without encircling the 
abdomen. 

If there should be need of the spine being more firmly supported, 
and the weight of the head removed from it, it may be done with the 
instrument (Fig. 237) seen in the annexed woodcut, consisting of a 
pelvic strap supporting two lateral uprights reaching beneath the 
axillas ; posteriorly two other uprights run up along the spine and 
bear at their apices two pads, which may be shifted up or down, accord- 
ing to the position of the angle upon the sides of which they repose ; 
a soft belt extends between the pads and gives support to the apex of 
the angle. The vertebral rods support a bifurcated curved metallic 
stem which slides up and down upon them, and may be secured with 
thumb-screws ; at its upper extremity it bears a cbin sling and occi- 
pital strap, which hold the head securely. To give additional steadi- 
ness to the apparatus the pads are connected by two lateral straps to 
the crutches of the axillary supports. 



314 APPAEATUS FOE EEMEDYING- LOSS OF SYMMETRY 
Fig. 237. Fig. 238. 





Apparatus for angular 
curvature. 



The same applied. 

The apparatus is applied as seen in Fig. 238. 
Loss of Symmetey of the Pelvis. — Obliquity of the pelvis is 
sometimes a result of anterior or lateral curvature of the lumbar ver- 
tebra^ or the cause may be in the pelvis itself; in the latter instance 
the obliquity will react upon the spine, and cause the formation of two 
or more curves in it, to restore the disturbed equilibrium of the body. 
One of the most common causes of this deformity is irregularity of 
length of the lower extremities produced by various agencies, as dis- 
ease of the hip and knee-joints. 

Young persons are the chief sufferers, and in some of these cases the 
carrying of heavy loads, the bad habit contracted by some children of 
supporting the weight of the body upon one leg while standing, or 
upon one hip while sitting, will be found the causative agents of nu- 
merous instances of pelvic obliquity presenting themselves to the 
notice of the surgeon. 

This deviation is much more easily prevented 
than remedied. The cause of an incipient pel- 
vic obliquity should be at once sought out and 
removed. For instance, if one leg is shorter 
than the other, by measuring with a tape line 
from the anterior superior spinous process of 
the ilium to the inner malleolus, the difference 
in length should be at once made up by a thick 
sole boot. 

If the deformity has become firmly esta- 
blished an effort may be made by means of ad- 
hesive strips applied to the shortened leg and 
weighted to draw down the elevated hip ; coun- 
ter-extension can be made from the shoulders 
by passing a roller bandage under the armpits 
and fastening them to the head of the bed. 
An ingenious contrivance used in this coun- 

Apparatus for obliquity of the . ■/? ?t •, o .i i • rn- 

pelvis> try tor obliquity of the pelvis, as seen in h lg. 



Fig. 239. 




OF THE UPPER EXTREMITIES. 



315 



239, is composed of a lateral stem with a check-joint at the hip pre- 
venting its lower part raising perpendicularly. The upper part of this 
stem projects from the hip of the longest leg to the axilla, where it 
terminates in a crutch, and is secured to the chest by a broad webbing 
band ; the lower part extends from the stop-joint to beyond the mid- 
dle of the thigh to which it is attached by a padded plate ; a pelvic 
strap gives additional security to the instrument. Its action in cor- 
recting the deformity consists in the drawing outward of the longer 
leg when a step is being taken, which must of course raise the hip 
and tilt the pelvis towards the short leg. 

SECTION III. 

APPARATUS FOR REMEDYING LOSS OF SYMMETRY OF THE UPPER 
EXTREMITIES. 

Deformity of the Fixgers. — Contraction of the fingers is the 
deformity with which the surgeon has most often to deal in the upper 
extremities. It arises from various causes, and is either congenital or 
non-congenital. One finger may be affected only, or the whole of 
them at the same time. 

The congenital cases are occasionally associated with deformities of 
other parts, as club-foot, and will be found to depend most alway upon 
a shortened condition of the skin upon the anterior aspect of the fin- 
gers, as shown in the annexed sketches (Figs. 240 and 241). 



Fig. 240. 



Fig. 241. 





Congenital deformities of the fingers. 



The most common cause, perhaps, of non-congenital contraction is 
thickening and diminution in the length of the palmar fascia. This 
condition is often seen to a limited extent in the hands of old sailors, 
and those engaged in laborious pursuits requiring the frequent use of 
the hand in grasping cylindrical objects, as ropes, and the handles of 



316 APPARATUS FOR REMEDYING LOSS OP SYMMETRY 

the various kinds of tools used by artisans ; the fascia sometimes even 
becomes nodulated. This condition is shown in Figs. 242 and 243. 



Fig. 242. 



Fig. 243. 





Deformities of the fingers from contraction of the palmar fascia. 

The late war has also furnished numerous cases of this deformity 
originating from gunshot and incised wounds of the forearm, hand, or 



Fig. 244. 



Fig. 245. 




Deformity of the fingers from wound of the forearm. 

fingers. Fig. 244 represents a case 
of the kind from a cut across the 
flexors of the forearm. 

Rheumatic and gouty inflamma- 
tion will produce similar results, 
and in some of these instances, be- 
sides the contraction of the fingers, 
irreparable injury is also inflicted 
upon the joints, rendering all hope 
of restoring their functions hope- 
less. 

Contraction of the skin upon the 
anterior faces of the fingers will also produce and maintain the 
fingers in a permanently flexed position, as seen in Fig. 245. 




Deformity of the fingers from contraction of the 
skin. 



OF THE UPPER EXTREMITIES. 317 

Lastly, the destruction of the muscular equilibrium of the flexors 
and extensors by paralysis of the latter, will give rise to some of the 
most troublesome cases of contraction that the surgeon is called upon 
to remedy. 

In the treatment of this deformity, if the flexor tendons are strongly 
contracted, tenotomy may be required before the application of me- 
chanical apparatus ; while, on the other hand, these appliances will 
suffice, in the majority of cases, alone in remedying contraction de- 
pending upon abnormal conditions of the skin, cellular tissue, and 
palmar fascia. 

Mr. Tamplin frequently availed himself of the elastic force of a 
common watch-spring, bound to the dorsal aspect of the contracted 
finger ; if more force was required than could be exercised by one 
spring, two or three of them were fastened together. 

The instrument of M. Duchenne, already described, will answer 
occasionally. 

In obstinate cases metallic stems, extending along the fingers, 
jointed at the digital articulations with ratchet-centres, and supported 
upon a metallic plate fitting the dorsum of the hand, will have to be 
employed. 

Deformities of the Wrist. — The deformities encountered in the 
wrist are: 1. Permanent flexion from contraction of the flexors. 
2. Permanent extension from contraction of the extensors. 3. Per- 
manent abduction from contraction of the abductors. The first form 
is most common. The causes are rheumatic inflammation about the 
wrist-joint, and traumatic injuries and paralysis of the muscles of the 
forearm. The flexed position of the wrist (Fig. 246) admits of relief 

Fig. 246. 




Contraction of the wrist, 



by mechanical apparatus, which, by exercising a gradually extending 
force upon the parts, brings them into their normal position, when the 
joint may be exercised by means of elastic cords. A patient came 
under my care with contraction of the wrist and fingers from being 
violently pressed between two ships. The parts had been in this 
condition for seven months. I applied an apparatus seen in Fig. 247, 
to extend the joint. It consists of a padded forearm splint, to which 
is attached two lateral arms, extending to the basis of the index and 
little fingers, jointed opposite the wrist, and moved by a ratchet-centre 
and key. Extending between the two arms across the dorsum of the 
wrist is a padded plate ; a strap encircles the metacarpus to sustain 
the ends of the arms. In this arrangement, by turning the key of the 
ratchet-wheel force is brought to bear upon the back of the wrist by 



318 APPARATUS FOR REMEDYING LOSS OF SYMMETRY 



Fig. 247. 



the padded plate, while the counter pressure is made upon the palm 

of the hand and forearm. 

When the patient's hand was ex- 
tended, the fingers were slipped into 
a sort of glove, inclosing only a 
narrow portion of the hand beyond 
their base. To this border a metallic 
strip was sewed, perforated with four 
holes ; a wristlet was then applied, 
with a perforated metallic strip also 
attached to its lower margin ; lastly, 
these two pieces of the apparatus 
were joined together by four elastic 
cords, provided with hooks. By per- 
severing with the use of this mechan- 
ism, the functions of the hand were 
restored in four months. If the wrist is permanently extended, the same 
apparatus may be employed by simply altering the position of the dorsal 
plate, which must now be made to press against the fore-part of the 
wrist. 

Fig. 248. 




Apparatus for deformity of the wrist. 




Apparatus for deformity of the wrist. 

Permanent abduction, occurring from the contraction of the mus- 
cles upon the radial border of the forearm, may be overcome by the 
following mechanism (Fig. 248). Apply to the forearm a padded me- 
tallic splint, from the back part of which a short arm projects as far 
as a sheath fitted to the lower part of the hand, and to which it is 
fastened, r Over the centre of the wrist this arm has a ratchet-centre, 
permitting lateral motion. To increase the adducting power still fur- 
ther, a lever-strap, attached by one extremity to the back part of the 
hand-sheath, passes around its ulnar border, to be fastened by the 
other to the posterior surface of the arm-splint. 

Fig. 249. ■ 




Contraction of the elbow. 



OF THE UPPER EXTREMITIES. 319 

Deformities of the Elbow. — The elbow may become perma- 
nently flexed (Fig. 249), or permanently extended from inflammation 
of the joint from any cause — rheumatism, contusions, fractures, and the 
like, where the arm is kept in a bent position for a long time. One 
case, coming under my observation, resulted from the wheel of a small 
gun-carriage passing over the arm below the shoulder ; no fracture 
was produced nor even the skin broken. 

The mechanical treatment of these cases consists in gradually ex- 
tending and flexing the arm, until the elbow is freely movable, and 
the muscles resume their functions. The contrivance of Stromeyer, 
modified by Mutter, as seen in Fig. 250, is commonly employed to 
make the extension ; the force being obtained by an anterior screw 
connecting the upper and lower splints. This arrangement causes an 
unpleasant amount of pressure at the upper part of the arm and lower 
part of the forearm, while the elbow tends to project posteriorly. A 
better form of apparatus may be constructed in which the articula- 
tion of the lateral levers is moved by a key acting upon a ratchet- 
centre, while the elbow is prevented projecting posteriorly by a padded 
strap passing across it. 

Fig. 250. Fig. 251. 




Stromeyer's apparatus for anchylosis of the elbow. Bonnet's apparatus for the same. 

Bonnet has constructed an instrument of great power to effect the 
same purpose (Fig. 251), and it is superior to that of Stromeyer. It 
consists of a padded splint fixed to a board, in which the arm reposes. 
In the centre of this board two vertical metallic pins are placed to 
which two lateral levers are articulated at a point corresponding with 
the centre of motion of the elbow and extending along the forearm 
to which they are connected by a padded belt. The joint of the lever 
is the centre of a graduated metallic arc fastened to the side of the 
board to indicate the extent of movement, and bearing a thumb-screw 
to arrest and hold the levers at any desired angle. 

Deformities of the Shoulder. — Contractions of the shoulder- 
joint are of exceedingly rare occurrence, and always result from 
inflammation in the articulation itself, or the soft tissues surrounding 
it. Chelius recommends the application of blisters, or other irritating 
remedies, for the purpose of inducing absorption of the interstitial 



320 APPARATUS FOR REMEDYING LOSS OF SYMMETRY 

deposit originating in rheumatic, or other inflammation of the soft 
parts about the joint; and the cautious use of an extending apparatus. 
An appropriate instrument may be constructed in the following 
manner : Make an exact mould with gutta percha, of the shoulder ; 
and attach to the upper and lower margins two short metallic pins, 
to the apices of which two levers are to be articulated with the axis 
of motion corresponding to that of the joint itself, by means of two 
ratchet-centres moved with a key. Attach the levers to the arm by 
means of a padded strap. 



SECTION IV. 

APPARATUS FOR REMEDYING LOSS OF SYMMETRY OF THE LOWER 
EXTREMITIES. 

Deformities of the Toes. Contraction of the Toes. — This 
deformity, which may affect one toe separately, or all of them at the 
same time, depends upon rheumatic inflammation of the small joints, 
or mechanical agencies producing such amount of irritation as to 
cause permanent contraction of the flexor muscles inserted into the 
phalanges, and the consequent displacement of them downwards; 
the wearing of narrow, short, and high-heel boots, for instance, is 
perhaps the most common cause. Fig. 252 illustrates the effects of a 
short boot upon the great toe, which is instinctively drawn back by 
the patient to avoid the pain. 



Fig. 252. 



Fig. 253. 





Contraction of the big toe. 



The "hammer toe.' 



Fig. 253 is an example of permanent flexion of the second toe 
sometimes called "hammer toe," which forms a sharp angle up- 
wards at the juncture of the proximal with the second phalanx. 
Fergusson says, that " it seems to occur most frequently in the origi- 
nally well-formed foot, in which this toe is a little longer than the 
others ; and though probably a short shoe is the chief cause of the 
displacement, I imagine that there is a natural tendency to it, from 
the slender shape of the part and the influence of the flexor and ex- 
tensor muscles. The latter seem to draw the distal extremity of the 
first phalanx upwards and backwards, whilst the former apparently 
have most effect on the furthest end of the toe, and, by drawing it 
downwards, increase the displacement." 

In many of these cases of deformities of the toes the contracted 



OF THE LOWER EXTREMITIES. 



321 



flexor tendons will have to be divided, after which a narrow splint 
must be placed beneath the toe to which it is fastened by a narrow 
strip of adhesive plaster. 

Mr. Tamplin used, as an extension apparatus for the great toe, an 
iron plate made to fit the sole of the foot, having attached to its 
anterior extremity a raised spring, to correspond with the position of 
the toe ; the splint is applied by means of strapping and bandage, 
with which any degree of pressure can be used. Success in restoring 
the joint to its extended position generally follows in the course of a 
couple of weeks. 

I have seen one case where all the toes were in a position of forced 
extension, occurring in a perfectly healthy person. The deformity 
came on gradually, without any ascertainable cause, and required 
the tendons of the extensor to be cut, and the toes to be brought down 
by means of an apparatus composed of a metallic plate made to fit the 
sole of the foot, from the anterior part of which a curved stem projected, 
bearing a padded plate moved vertically by a screw, with which pres- 
sure was brought against the upper surface of the toes. 

Bunion. — This deformity consists in the displacement of the head 
of the first metatarsal bone inwards, while the proximal phalanx is 
pressed outwards, thus making an angle at the first metatarso-phalan- 
geal articulation, and separating to some extent the internal margins 
of its articular surface. It is always caused by wearing narrow-toed 
boots, or those having high heels, which throw a part of the weight 
of the body upon the ends of the toes. The deformity is seen in 
Fig. 254. A similar protuberance is sometimes formed over the fifth 
.netatarso-phalangeal joint. The mechanical treatment of bunion is 
simply to discontinue the narrow-toed boot and substitute one with 
soft uppers and with a straight internal edge from the heel to the toe. 



Fig. 254. 



Fig. 255. 





Appearance of bunion. 



Apparatus for bunion. 



An ingenious apparatus is sometimes employed to diminish this 
deformity. As seen in the figure (255), it ^consists of a short lever 
with a ring-joint at its centre, which reposes upon the bunion; the 
21 



322 APPARATUS FOR REMEDYING LOSS OF SYMMETRY 



stem is connected above to a laced bandage around the instep, and 
below it projects to the point of the toe, which is drawn out towards it 
by a little bandage. 

Deformities of the Foot and Ankle. Club-Foot. — This de- 
formity consists in the deviation of the foot in various directions from 
the normal form, and thus several varieties are met with, which are 
modifications, more or less, of four different types, viz: talipes varus, 
talipes equinus, talipes valgus, and talipes calcaneus, named in the 
order of their frequency. 

In the first variety or talipes varus (Fig. 256) the foot is inverted, 
the outer malleolus is depressed, the heel raised from the ground, and 

the toes pointed inwards, compelling the 
Fig. 256. patient to support the weight of his body 

upon the middle of its outer border. 
The dorsum of the foot is more convex 
and the sole more concave, while the con- 
stant irritation of the soft parts against 
which the pressure comes causes them to 
thicken, and a bursal sac to be formed 
in many cases, which answers the pur- 
pose of a soft cushion to ward off' danger 
to the parts below. In slighter cases of 
this deformity the foot can be restored 
to its natural position by the hands of 
the surgeon, though it resumes its ab- 
normal one immediately, and no changes 
in the soft tissues or bone have as yet 
taken place. 

Talipes varus. Varus is most always congenital, and 

has been observed in rare instances to 
be hereditary ; in other cases it occurs subsequent to birth, and is caused 
by deranged innervation from teething, convulsions, neuralgia, para- 
lysis, by keeping the foot in the same posture for any lengthy period, 
as may happen in fractures, wounds, or by anything which disturbs 
continuously the equilibrium of the muscles. 

The changes that occur in the parts consist in elongation of the 
muscles upon the outer margins of the leg and foot and a correspond- 
ing contraction of those upon the inner sides ; the bones of the tarsus, 
especially the os calcis, astragalus, scaphoid, and cuboid become more 
or less separated and rotated upon their axis without being dislocated 
from their natural cavities. If the deformities have existed for a long 
time, the bones then alter in shape, and become fixed in their unnatural 
positions. 

Treatment — After the operation, if tenotomy be required, the foot 
must be alternately flexed and extended to break up all morbid bands 
and adhesions, and an appropriate apparatus applied, which should be 
put on loosely the first few days, until the leg becomes accustomed to 
its presence, then tightened up gradually until the object is attained. 
The instrument must be worn night and day. It will add much to 
the comfort of the cure, and facilitate it, to some extent, if we sponge 




OF THE LOWER EXTREMITIES. 323 

the leg daily with the camphorated soap liniment, and use gentle 
friction for a few minutes. 

As to the selection of a proper mechanical appliance, it should be 
remembered that the foot has undergone a threefold alteration in its 
position in relation to the leg, being in exaggerated extension, adduc- 
tion, and rotation, so that the indications to be fulfilled in varus are 
flexion, abduction, and retroversion. 

An apparatus that will answer in most of the congenital cases, and 
is easily obtainable, may be prepared by the surgeon in the following 
manner with adhesive strips, as recommended by Chelius : Take five 
or six strips of adhesive plaster, long enough from the foot to reach 
to just above the knee, and about an inch wide. Have the foot drawn 
into as natural a position as possible by an assistant, then apply the 
strips one after another, commencing upon the instep; make a turn 
about it, drawing the strips around its outer border, and then carry 
them up the leg ; to render the whole secure, two or three circular 
pieces may be also put on. A splint is now to be placed upon the 
external side of the limb, projecting two inches beyond the sole of the 
foot, to which it must be bound by a figure of 8 bandage. 

It has lately been the custom of some American surgeons to employ 
the elastic force of India-rubber in the treatment of club-foot. It ex- 
ercises a constant, but yielding power in rectifying the distorted posi- 
tion of the foot; the rubber cords being put in such relation with the 
limb as to take the place and perform the functions of those muscles 
that have become abnormally elongated and weakened. 

From the changes that always ensue, in the position of the tarsal 
bones, in the structure of ligaments and the muscles of the limb dur- 
ing a long-continued malposition of the foot, it requires patient and 
persevering employment of the treatment to secure a successful issue. 

In congenital and a certain number of the postgenital cases the 
present plan will succeed without tenotomy, yet this operation is an 
invaluable resource in many instances, and the surgeon has, with pre- 
sent experience, little ground for hoping that it can be ever altogether 
laid aside for mechanical contrivances, as has been thought by some. 
With a clearer insight into the mechanism of club-foot the surgeon will 
be enabled to restrict tenotomy to those tendons only which offer an 
insurmountable resistance to the restoration of the foot to its normal 
posture; he can thus avoid that indiscriminate cutting of the various 
tissues about the ankle, often erroneously supposed to participate in 
the causation of the deformity, which has been practised in too many 
cases unnecessarily, with permanent injury to the patient. 

Even in those cases apparently insurmountable, by the persevering 
use of elastic traction, success maybe obtained, at least by assisting the 
action of the rubber-cords with force judiciously applied with the 
hands, while the patient is under the influence of an anaesthetic. 

As the tractile cords are intended to supplement the impaired power 
of the muscles, they should be made to act as nearly as possible in the 
line of the muscles they represent. 

To attain this object Mr. Barwell has suggested an ingenious plan 
of fastening them to the limb. In order to get an upper point of 



324 APPARATUS FOR REMEDYING LOSS OF SYMMETRY 

attachment he secures to the leg an oblong piece of tin by taking a long 
strip of adhesive plaster, and applying half of its length to the tibia 
from the knee to just above the ankle ; the strip of tin, which should 
be a little narrower than the adhesive plaster, is laid upon this, then 
the free end of the strip is carried up in front of the tin, with its 
adhesive side looking forwards ; a roller bandage or circular strips 
of plaster should now be applied to the leg, and the terminal end of 
the strip brought down over the bandage so as to secure all. A wire 
loop is inserted into the upper end of the tin. 

The lower point of attachment is established by applying across the 
bottom of the foot a trapezoid piece of adhesive plaster, with an eyelet 
in one of its corners ; it is secured to the part by circular strips of the 
same material. 

The rubber spring is stretched between these two points above and 
below by means of catgut cords. In talipes valgus the tin will be 
placed upon the anterior surface of the tibia, and but one elastic cord 
need be used, extending in the direction of the tibialis anticus, be- 
tween the wire loop at the upper end of the tin plate and the eyelet 
in the plaster. In talipes varus the tin is secured just behind the 
fibula, and two traction cords are employed ; the anterior one passing 
in front of the external malleolus, and representing the peroneus ter- 
tius, the posterior behind the malleolus, in the direction of the pero- 
neus longus and brevis. 

In cases in which the patient has walked, the weight of the body 
upon the margin of the foot approximates the external and internal 
arches of its sole ; in other words, produces a longitudinal folding, 
which becomes gradually effaced by the same cause that produced it, 
namely, the weight of the body after the foot has been sufficiently 
abducted by the above described plan of treatment. 

Dr. David Prince, of Illinois, has suggested a simple and efficient 
method of accomplishing the same object with the following contriv- 
ance : " For a patient ten years old take a sheet of gutta-percha one- 
third of an inch thick, or a sufficient number of thinner sheets to 
make that thickness, long enough to encircle the foot, and wide enough 
to extend from the middle joint of the phalanges to the medio- tarsal 
articulation, i. e., the joint between the scaphoid and astragalus above, 
and the cuboid and calcaneum below. 

"Apply upon both surfaces of the gutta-percha an investment of 
muslin of good strength, and lay the whole, thus prepared, into a pan 
of water nearly boiling hot. While the softening process is going on 
the foot should be wrapped with a roller, protecting the prominent 
points with pledgets of lint or cotton. 

"As soon as the gutta-percha is thoroughly softened, it is taken out, 
still lying between its muslin investments, and so applied that its ends 
come together on the outside of the foot (in talipes varus), where the 
two extremes of gutta-percha should be welded by pressure between 
the thumb and fingers, previously dipped into cold water, to keep the 
material from sticking to the fingers. 

"In talipes valgus, the extremities of the gutta-percha meet and pro- 
ject on the inner or median side of the foot. While the material is yet 



OF THE LOWEE EXTREMITIES. 325 

warm and yielding, a square piece of pasteboard is laid upon the 
dorsal surface of the foot, with a corresponding piece of oiled-silk or 
rubber-cloth underlying it to prevent its softening by the moisture of 
the wet muslin investment, and a similar piece of pasteboard is applied 
directly opposite upon the plantar surface. 

"A common pair of calipers, with screw fastening, is then applied, 
so that one leg rests upon the pasteboard upon the dorsal, and the 
other upon the pasteboard upon the plantar surface. The screw is 
then turned, to secure very firm squeezing between the opposing points. 
This compression is continued until the gutta-percha has become hard 
and unyielding, except by its elasticity. After this, the calipers are 
removed. 

" A hole is then punched through the projecting gutta-percha, along- 
side of the metatarsal bone of the little toe in varus, and of the great 
toe in valgus. Into this hole a cord is inserted, which is fastened to 
a rubber ribbon or piece of rubber tube or cylinder, which must again 
have its attachments above by adhesive bands below the knee, above 
the knee, or by a padded roll to the pelvis, which is thereby encircled. 
This last is the least troublesome attachment, as it can at any time be 
slipped off and put on again. In the last method, a knee-cap is neces- 
sary to make the tension-cord follow the angle of the limb in walk- 
ing and sitting. The appliance to the foot should be removed and 
reapplied every day in hot weather, and every alternate day in cold 
weather, to avoid excoriation from pressure and retained exhalations." 

Dr. Alfred C. Post extols the gutta-percha shoe in the treatment of 
talipes. The material of which he constructs these shoes "is a gutta- 
percha sheet from a sixteenth to an eighth of an inch in thickness. 
It is cut of such a shape as to adapt itself to the sole and sides of the 
foot, leaving a space uncovered on the dorsum of the foot equal to 
about one-third of the breadth of the foot; it is also adapted to the 
sides of the leg, extending up two-thirds of the distance to the knee, 
and leaving a narrow space uncovered before and behind, each space 
so uncovered being about one-sixth of the circumference of the leg. 
The material is readily moulded to the shape of the limb by immersing 
it for a few seconds in water at a temperature of 100° Fahrenheit. He 
is in the habit of moulding the shoes, thus heated, over a wooden last 
made for the purpose. The last is not made after the fashion of a 
bootmaker's last, but it is shaped like the natural leg and foot, except 
that the outer side of the foot is made to correspond with the inner, 
thus obviating the necessity of having separate lasts for the right and 
left foot." 

He generally commences the treatment of infantile club foot by 
the subcutaneous division of the tendo-Aohillis, after which he applies 
a strip of isinglass plaster over the small wound of the skin. He then 
has the foot held by an assistant as nearly as possible in its normal 
position, and while it is so held he carefully applies a roller bandage so 
as to cover the foot and leg, beginning the application on the outer 
side of the ankle. He then applies the gutta-percha shoe, an assistant 
grasping the leg with one hand, pressing the upper part of the shoe 
against the sides of the limb, and with the other hand pressing the 



326 APPAEATUS FOR REMEDYING LOSS OF SYMMETRY 



sole of the shoe against the sole of the foot. While the shoe is thus 
firmly pressed against the leg and foot, he applies a roller bandage 
firmly, so as to secure it in its place. After the lapse of twenty -four to 
forty-eight hours he takes off the bandages and shoe, washes the foot, 
wipes it dry, uses passive motion freely in different directions, and then 
reapplies the apparatus as before. The application is repeated at inter- 
vals of two or three days, until the foot is brought to its proper shape, 
when it is put up in a laced boot, lacing to the toes, and having a firm 
sole and stiff sides, provided with iron braces which extend nearly as 
high as the knee, and secured by a strap and buckle around the upper 
part of the leg. 

Good sole-leather, pasteboard, tin, or some similar material, may 
be moulded to the limb in the same manner, forming serviceable and 
efficient splints. 

Various other contrivances for the treatment of club-foot have been 
introduced to the notice of the profession, from time to time, by various 
surgeons and surgical instrument makers ; all of them being modifi- 
cations, of greater or less merit, of " Scarpa's shoe." The apparatus 
of this surgeon is rather complex, consisting of a thinly-padded me- 
tallic sole, to the posterior portion of which a semicircular piece of 
metal is attached, to embrace the heel above its point ; a side-stem is 
connected with the heel-piece by ratchet centres in such a manner as 
to permit antero-posterior and lateral motions at points corresponding 
with the ankle ; a curved spring also projects from the heel-piece 
along the inner side of the shoe, which is intended, by its pressure, to 

straighten the foot. The apparatus is 
connected to the limb by a metallic strap 
placed at the top of the side-stem, to en- 
circle the leg below the knee, and by a 
number of leather straps and buckles. 

A more simple and efficient apparatus 
is the one seen in Fig. 257, designed by 
Mr. Kolbe, of Philadelphia. It consists of 
two lateral metallic straps jointed at the 
knee and ankle, extending from the lower 
third of the thigh to a shoe of peculiar con- 
struction. They are movable upon each 
other, so that the instrument may be 
adapted to limbs of different lengths, and 
are connected to the leg by three padded 
metallic straps, one encircling the thigh, 
and the other two the leg. The shoe is 
composed of a lacing upper of soft lea- 
ther, attached to a metallic sole divided 
into two sections, and movable laterally 
upon each other at a point corresponding 
with the medio-tarsal articulation, that is 
at the junction between the os calcis with the cuboid bone below, and 
the astragalus, with the scaphoid, above. The mechanism of motion 






Fig. 257. 




Kolbe's club-foot apparatus. 



, 



OF THE LOWER EXTREMITIES. 



327 



simply a ratchet arrangement concealed in the sole of the shoe, and 
controlled by a key fitting to a screw-head placed upon its margin. 

A short screw extends between the side-stem and the shoe, to move 
the latter antero-posteriorly upon a joint placed in the lateral sterns at 
a level with the tibio-astragalal articulation. 

When the instrument is applied the foot is firmly secured in the 
shoe by a broad strap encompassing the limb above the malleoli, and 
connected with the metallic sole by three smaller straps at its poste- 
rior and lateral sides. 

There is no provision for lateral motion at the ankle, as in the con- 
trivance of Scarpa ; a complication of the apparatus that is entirely 
unnecessary, inasmuch as the foot can readily be abducted with the 
hand before it is encased in the shoe. The instrument is constructed 
with a view of first converting a talipes varus into a talipes equinus, 
and then bringing down the heel into its normal position. 

Dr. Little, of London, has also invented a contrivance (Fig. 258) for 
varus. It is constructed with a padded metallic shoe, to which one side- 



Fig. 258. 



Fig. 259. 




Dr. Little's club-foot apparatus. External and internal views. 

stem for the perineal edge of the leg is movably articulated ; the move- 
ment of flexion between them being controlled by a long screw ex- 
tending between the stem and heel of the shoe. The foot is secured 
in the shoe by a broad belt passing over the metatarsus, and two 
straps crossing the instep. A padded strap connects the side lever 
to the leg below the knee, while another strap, placed above the 
malleoli, and connected by two straps to the shoe, prevents the heel 
rising vertically. The broad strap seen in the figure, running between 
the upper strap and shoe, is intended to check any sudden abduction 



328 APPARATUS FOR REMEDYING LOSS OF SYMMETRY 



of the foot. When the screw is turned, the heel is gradually brought 
down, there being no further provision made to correct the adduction, 

while rotation is in some de- 
gree corrected by the ankle- 
straps. 

A modification of this instru- 
ment (Fig. 260), sometimes em- 
ployed, has a horizontal lever 
reaching to the point of the big- 
toe from the heel of the shoe, and 
bearing a strap at its extremity 
to encircle the metacarpus, and 
by its pressure abducting the an- 
terior part of the foot. 

Talipes Equlnus. — This de- 
formity, seen in Figs. 261, 262, 
consists in a permanent contrac- 
tion of the gastrocnemius and 
soleus mucles, raising the heel 
from the ground to a greater or 
less extent, and bringing the foot, 
the dorsum of which is unusually 
convex, with a corresponding con- 
cavity in the sole, nearly to a 
straight line with the leg, the weight of the body being borne upon 
the metatarsus and toes. In most cases, however, the foot inclines some- 




Dr. Little's apparatus modified. 



Fig. 261. 



Fig. 262. 





Talipes equinus. External and internal views. 



what inwards or outwards; and when this occurs to any extent, it 
merges into the varieties called equino-varus and equino- valgus. 
In children talipes equinus is caused by the irritation of teething, and 



OF THE LOWER EXTREMITIES. 



329 



worms ; in adults, by wounds of the leg, scrofulous disease of the joint, 
and rheumatism. According to Mr. Tamplin, it is rarely congenital. The 
principal displace- 
ment of the tarsus is Fig. 263. 
a depression of the 
scaphoid and the 
projection of the 
head of the astrag- 
alus upon the top of 
the foot, while the 
tibia is displaced 
backward upon the 
facet of the astrag- 
alus. 

Treatment. — This 
form of club-foot is 
perhaps the easiest 
to treat mechanic- 
ally, the indication 
being to draw down 
the heel after the di- 
vision of the tendo- 
Achillis. 

One of the earliest apparatus employed for this purpose was what 
is known as " Stromeyer's foot-board." It consists, as seen in Fig. 
263, of a posterior splint which is fastened to the posterior surface 
of the leg by straps ; to its lower part, a foot-board is attached by an 
axis, permitting vertical motion, and moved by cords winding around 
a windlass, situated at the 




Stromeyer's apparatus for club-foot. 



bottom of the splint. The ac- 
tion of the instrument forces 
up the toes, and the heel de- 
scends in an equal ratio. 

When applied to the foot 
the patient cannot move about, 
as is easily seen by the con- 
struction of the apparatus. 

A modification of "Stro- 
meyer's foot-board," by Lis- 
ton, is seen in Fig. 264. 

It is formed of a metallic 
shoe with a lacing upper, to 
the sides of which two leg- 
stems are movably attached, 
and connected above by a 
padded strap. A second strap 
crosses the instep to prevent 
the heel ascending vertically. 
The instrument acts by mak- 
ing a fulcrum over the astraga- 



Fig. 264. 




Listou's apparatus. 



330 APPAKATUS FOR REMEDYING LOSS OF SYMMETRY 

lus by the instep strap, and a point of resistance at the metatarso- 
phalangeal articulation ; force now applied to the levers will neces- 
sarily cause the heel to descend. 

The first instrument described for the treatment of varus is also 
arranged in such a manner that it may be used for equinus. 

Talipes valgus is the contrast of varus, and much less common 
than either of the two former varieties of these deformities. The foot 
is everted, the heel drawn up, the toes elevated, and the weight of the 
body is supported upon its inner margin ; it has in fact become ab- 
ducted, flexed, and rotated outwards. 

The changes in the directions of the bones, in a case examined by 
Dr. Little, were : " The astragalus is twisted in such a manner that the 
articular facet, which ought to be applied against the inside of the 
internal malleolus, did not enter the composition of the ankle-joint, 
but was turned downwards; the navicular bone and calcaneum 
followed the astragalus, and, together with the internal malleolus, 
would have touched the ground with their internal surfaces, if the feet 
had belonged to subjects who could have walked. The external edge 
of the os cuboides, and fifth metatarsal bone, and external surface of 
the calcaneum presented directly upwards; the latter, therefore, was 
in contact- with the external malleolus, the prominence of which could 
not be felt through the foot." 

Valgus is generally produced by traumatic injuries, and is seldom 
congenital. 

Treatment. — After the division of the tendons of the peroneus longus 
and brevis, and the extensor communis, if it be necessary, the proper 
mechanical apparatus for counteracting the deformity consists of a 
simple splint extending from the knee to the inner malleolus, from 
the lower extremity of this a spring projects along the inner border 
of the foot, having a soft pad attached to it to make pressure beneath 
the scaphoid ; the end of the spring is bound to the forepart of the 
foot by a bandage or strip of adhesive plaster. With this apparatus 
gradually raise the arch of the foot, when an ordinary shoe with a pad 
fastened to the inside of it, at the inner margin of the sole, may be 
worn. The apparatus of Kolbe is also adapted to the treatment of 
valgus. 

As the method of treating varus with elastic cords has already been 
fully explained, it is simply necessary to remark in this place that the 
same mode may also be adopted in valgus, the only modification re- 
quired being that the cords must be made to act upon the inner margin 
of the foot instead of the outer, as in varus. 

In simple yielding of the instep inwards, constituting splay-foot, a 
shoe with an India-rubber pad to rest beneath the scaphoid will be of 
great service. Some recommend that a curved metallic spring be in- 
troduced in the sole of the boot lengthwise the arch, but this is not so 
good as the pad. 

Talipes Calcaneus. — This form of club-foot was so named, by 
Dr. Little, because the heel alone rested upon the ground (Fig. 265), 
while the rest of the foot stuck upwards, forming a more or less acute 
angle with the leg. This deformity is always congenital, and when seen 



OF THE LOWER EXTREMITIES. 



331 



immediately after birth the foot may be easily restored to its natu- 
ral position. It is accompanied with little or no displacement of 
the tarsal bones. A simple contrivance for correcting the defor- 
mity will be found in the application of a splint made of gutta- 
percha moulded to the back of the leg and sole of the foot while they 
are in a rectangular position. 

A more complicated and expensive, but no less efficient appa- 
ratus for talipes calcaneus, is seen in Fig. 266, which is constructed 



Fig. 265. 



Fig. 266. 





Appearance of talipes calcaneus. 



Apparatus for talipes calcaneus. 



Fig. 267. 



with two metallic side-stems articulated at the knee and ankle, and 

connected to the limb with padded metal straps ; they are connected 

below to the sole of a lacing shoe. Above and below 

the ankle-joint two metallic rods arch over the posterior 

margin of the leg between the side-stems, to which they 

are strongly riveted, and are connected on the posterior 

median line by a spiral spring, which constantly exerts 

an extending power upon the foot. The spiral spring 

may be replaced advantageously by an elastic cord. 

In all cases of club-foot after the deformity has been 
entirely overcome by appropriate apparatus, it will be 
well to exercise the foot for some time with an ordinary 
shoe (Fig. 267), with two lateral stems ascending to a 
point below the knee, and articulated at the ankle-joint. 

Bowed or Baxdied Legs. — In this deformity, seen in 
Fig. 268, the knees are widely separated from each other 
and the legs curved outwardly, which gives the patient an 
awkward waddling gait; there is more or less weakness of 
the limbs, and fatigue in using them, for the reason that the 
weight of the body is not supported in the line of their axis. 

This condition does not depend, as knock-knee, upon a yielding of the 
ligaments of the knee-joint, but upon a curvature of the bones of the leg 




Shoe to be worn 
in club-foot after 
the deformity 
has been recti- 
fied. 



332 APPAEATUS FOR REMEDYING LOSS OF SYMMETRY 




Fig. 269. 



Fig. 270. 



Fig. 268. itself — the tibia and fibula — which, in children of 

an unhealthy constitution and surrounded by bad 
hygienic influences, are often affected with rachitic 
softening, in consequence of the altered proportions 
of the calcareous and animal constituents of the 
bone. The legs, thus rendered unable to support 
the weight of the body, generally yield outwards, 
though sometimes forwards, or in both of these 
directions — forwards and outwards — at the same 
time. 

In rare cases it affects but one leg, the other 
leg being curved inwards. 

Treatment. — The general treatment with tonics 
and alteratives should be directed to the improve- 
ment of the constitution, while mechanical means 
should be employed to straighten the legs. This 
can be accomplished in eighteen months or two 
years, among children to whom the deformity is 
always confined. After the body has acquired its 
normal stature, and the bones acquired solidity, 

Appearance of bowed legs. j^ ^ be aooomplished in the waj Q f cure> 

A simple appliance, that will be found as efficient as any, is seen in the 
annexed drawing (Fig. 269). It is a well-padded splint extending from 

the condyle of the femur to below 
the malleolus, along the inner side 
of the leg, to which it is bound by 
two straps ; three other straps pass 
around the splint and leg at the top 
of the curvature, intended to depress 
the arch formed by the curve of the 
tibia and fibula, while its abutments 
at the knee and ankle are sustained 
by the ends of the splint. 

Mr. Kolbe, of Philadelphia, has 
devised the apparatus seen in Fig. 
270, for bowed leg. It is constructed 
of two metallic side-stems jointed 
at the knee and ankle, connected 
above to a padded metal plate in- 
closing the lower part of the thigh, 
and below to a laced boot. These 
stems are sufficiently flexible to be 
bent so that the instrument may be 
accommodated to the curvature of 
any limb, how great soever it may 
be. Upon the inner stem there are 
placed two pads, one above, to rest upon the head of the tibia, the other 
below, to occupy a position over the inner aspect of the ankle ; these 
are intended as points of counter-pressure to the force exerted directly 
over the arc of curvature by the oval pad moving from the mid- 





Apparatus for bowed legs. 



OF THE LOWER EXTREMITIES, 



333 




Apparatus for anterior cur- 
vature of the leg. 



die of the outer vertical stem by means of two 
screws. 

In anterior curvature, alluded to above, an 
appropriate apparatus will be found in the con- 
trivance seen in the annexed wood-cut (Fig. 271), 
consisting of two metallic stems jointed at the 
ankle, and connected below to the sole of a laced 
boot, and above to a metallic padded strap, 
which encircles the leg below the knee ; between 
the side-stems two broad pieces of leather extend 
anteriorly across the convexity of the curved leg, 
and they are closed in front by a lacing cord 
running through their eyeleted margins. 

Contraction of the Knee-Joint. — Contrac- 
tion of the knee-joint, as the name implies, is the 
permanent bending of the leg upon the thigh at 
an angle. Its extent may vary from the slightest bend of the limb to 
the formation of a right or even an acute angle ; and exists alone or may 
be accompanied with contraction of the flexors or adductors of the 
thigh, or with contraction of the muscles of the calf of the leg ; in 
certain cases the tibia may be displaced a little laterally or poste- 
riorly, even rotated upon the femur, all of which complications will 
be considered under separate headings below, with the apparatus ap- 
propriate to their treatment. 

This deformity is caused by contraction of the hamstring muscles 
from paralysis, inflammation of the knee from rheumatism and injuries, 
by contraction and consolidation of the liga- 
ments and fibrous tissues about the joints, 
nervous irritation, as in hysteria, and by 
osseous anchylosis. 

Two plans of treatment are pursued : in 
the first, the patient is laid upon his face, 
and the surgeon, seizing the foot of the dis- 
torted leg in his right hand, and steadying 
the thigh with his left, forcibly extends 
the limb. In the second, the limb is moved 
by gradual extension by means of appara- 
tus either with or without tenotomy. 

When the contraction is in the mesial 
line the instrument that will be found as 
efficient as any other is shown in the wood- 
cut (Fig. 272), and was designed by Kolbe. 
It is constructed with padded metallic 
thigh and leg splints, connected by two 
lateral levers, articulations corresponding 
with the axis of motion of the knee-joint. 
"VYhen the force is applied by the screw 

connecting the splint posteriorly, the knee is prevented from springing 
forward by a padded ring placed over the patella and connected to the 



Fig. 272. 




Apparatus for contraction of the knee. 



334: APPARATUS FOR REMEDYING LOSS OF SYMMETRY 



upper and lower splints by four straps, and which form a fulcrum, or 
point of resistance, while the splints exercise pressure upon the an- 
terior surface of the thigh and leg. 

M. Bonnet used the apparatus seen in Fig. 273 for the purpose of 
restoring the functions of extension and flexion to the knee-joint. It 

Fig. 273. 




Bonnet's apparatus for contracted knee. 

is composed of two lateral rods connected beneath the sole of the 
foot, and extending up the sides of the limb to the upper part of the 
thigh, and jointed at the knee; the rods are joined posteriorly by broad 
metallic troughs to support the leg and thigh, and to which they are 
attached by anterior splints, buckles and straps. To sustain the limb 
at the proper elevation while it is being exercised, two strong rods 
project from the thigh-piece to a triangular frame which supports 
them. 

The motion is impressed upon the limb by a lever which is attached 
to the side-rods of the leg-piece beneath the knee; this is used to flex 
the leg; an extending cord runs from the arched portion of the in- 
strument beneath the foot, over a pulley placed upon the supporting 
frame, and is held in the patient's hand; with this the leg is ex- 
tended. 

The manner of applying and using the apparatus is shown in Fig. 
273. 

Mr. Tamplin invented an appliance (Fig. 274) to meet the indica- 
tions in that class of cases presenting lateral displacement along with 
flexion. It consists of leg and thigh splints connected together poste- 
riorly by a stem, with an articulation admitting of antero-posterior 
and lateral movements ; the power is applied by two screws, one upon 
the posterior and the other upon the lateral plane of the splints ; the 
knee is prevented springing forward by a knee-cap. Its action is 



OF THE LOWER EXTREMITIES. 



335 



similar to the one described above, with the difference that it has 
also lateral action. 

After the knee has been straightened, it has been observed in some 
cases that the tibia is displaced backwards, the condyles of the femur 
and the patella remaining fixed anteriorly, as seen in Fig. 275. The 



Fig. 275. 




Tamplin's apparatus for contracted knee. 

method of remedying this is to place the patient in a horizontal posi- 
tion, and make extension and counter-extension upon the leg until the 
head of the tibia is brought down, and then to apply an apparatus to 
retain it. For the latter purpose, Mr. Erichsen speaks flatteringly of 
an appliance designed and constructed by Mr. Bigg, of London. He 
thus describes it : "A and B are two levers, composed of metal, corre- 
sponding in their direction to the perpendicular position of the femur 
and tibia. C and D are two axes, placed exactly coincident with the 
centres of the articular ends of the bones. E and F are two powerful 
springs, whose action takes place in opposing directions, similar to the 
arrow indications in Fig. 276. This F presses the lever B in an ante- 
rior direction, bearing the end of the tibia forward ; whilst E presses 
the lever A in a posterior direction, bearing the end of the femur 



336 APPAKATUS FOE REMEDYING LOSS OF SYMMETRY 



backward. As C and D are found acting above and below the actual 
axis of the knee-joint, they mutually influence the point formed by 
the apposition of the heads of the tibia and femur ; and as it has 
already been explained that the femur really offers a fixed resistance, 



Fig. 276. 



Fig. 277. 



• "; Ul 




Bigg's apparatus for contraction of the knee. 

and the tibia moves beneath it, the head of the latter bone is turned 
anteriorly in a semicircular direction, consequent on the upper centre 
(C) being a fixed point, and the lower centre (D) rotating around it. 
Gr is an elastic knee-cap; H, a padded plate. When the ligaments are 
tense, there is a chance of pressing the anterior surface of the tibia 
against the posterior surface of the femur. This is readily obviated 
by having the shaft (A) made to elongate, when the centre (C), being a 
little lowered, pushes the lever (B) downwards, carrying the tibia with 
it, and thus separating the osseous surfaces of the joint." 

Contraction of the Hip-Joint. — Contraction of the hip consists 
in the thigh being bent upon the abdomen. In the greater number 
of cases there will be, besides flexion, more or less adduction of the 
thigh, by which the knee will be thrown towards or even across the 
opposite limb. 



OF THE LOWER EXTREMITIES. 337 

The causes of tbis condition are cerebral or spinal irritation, arthritic 
inflammation of the hip, violence inflicted upon the spine, and scrofu- 
lous disease of the hip-joint. 

In those cases originating from irritation of the brain or spinal cord, 
other muscles will be affected along with the flexors and adductors of 
the thigh ; there will generally be paralysis of the extensors of the 
leg and flexors of the foot, so that the muscles opposing them, being 
no longer counteracted, will by their action produce more or less con- 
traction of the knee and foot ; club-foot is also commonly associated 
with contraction originating from this source. 

In those instances again which spring from some violence impressed 
upon the line of the spine, paralysis of certain muscles will be induced, 
while their unopposed antagonists will contract and maintain the 
thighs abnormally bent upon the pelvis ; here, also, the legs partici- 
pate to a greater or less extent in the contraction. 

I have recently had under my care an adult in whom there was 
contraction of both thighs, originating from gouty inflammation of the 
coxo-femoral articulations. In cases of this description no paralysis 
will be found, as in the former instance ; the limbs are maintained in 
that position in which, during the acute stage of the inflammation, they 
have been instinctively drawn by the patient for the purpose of alle- 
viating the pain in the joints; the muscles insensibly contract and 
adapt themselves to the ne-w condition of things. 

But of all the above-enumerated cases of contraction of the hip, 
scrofulous disease of the joint, known under the name of hip disease, or 
morbus coxarius, is by far the most common. It begins almost always 
in the reticulated structure of the head of the femur, in young subjects 
between the ages of three and nine years. Cases have occurred 
inside of the first year, and as late as adult age, but they are rare. 
A case occurred in my practice, in which the patient was fifty-five 
years of age. While under treatment, which consisted in the applica- 
tion of a modified form of Davis's splint during the day, and the weight, 
cord, and pulley at night, the patient improved very greatly, so much 
so, indeed, as to induce him to quit the apparatus several weeks, 
during which time he took active exercise, and the consequence was 
that he was again brought to bed with acute symptoms of local inflam- 
mation of the hip-joint that ran on to suppuration, under which he 
ultimately sank. 

This disease, like other scrofulous affections, is slow and insidious 
in its approach, being scarcely marked in the early period of its course 
by sufficiently distinctive characteristics to be recognized, except by 
the medical attendant. 

In the first stage the child complains of weakness and weariness m 
the limb; he trips, in pursuing his accustomed amusements, with 
unusual frequency, and complains of pain in the knee corresponding 
with the diseased hip, although the knee does not present any evidence 
of disease. 

In a variable period, from a few weeks to as many months, pain 
is felt in the hip from the sensitive nerves of the bone having be- 
22 



338 APPAKATUS FOR REMEDYING LOSS OF SYMMETRY 

come involved, the limb, perhaps, loses a little flesh, but the patient's 
general health remains unimpaired. 

In the second stage the pain in the hip becomes more decided ; the 
health of the patient begins to fail, his digestive functions suffer, his 
sleep is disturbed, and there is some febrile excitement established. 
Along with the general wasting of flesh, the limb becomes attenuated 
and the gluteal region flattened ; the gluteo-femoral fold, so marked 
upon the healthy side, is, upon the diseased one, completely effaced. 

The limb is apparently elongated from the tilting of the pelvis 
toward that side ; the loins present a hollow, while the abdomen is 
unusually prominent ; the upper portion of the thigh becomes swollen 
and tender. 

In the third stage the local destruction has made constant progress ; 
the head of the femur and portions of the rim of the acetabulum are 
more or less removed by ulcerative action ; pus has formed about the 
parts, and, after burrowing in every direction, finally escapes exteriorly, 
generally in the gluteal region over the joint. The pain is severe, 
and is greatly aggravated by impressing movements upon the limb, 
which is now really shorter than the healthy one in consequence of 
the ravages in the head of the femur and cotyloid cavity. The hip, 
instead of being flattened, as in the beginning, is now prominent, and 
the thigh is more or less bent upon the pelvis, and generally some- 
what adducted. 

The severity of the constitutional symptoms keeps pace with that 
of the local changes, the patient suffering from severe febrile excite- 
ment and copious sweats. 

In rare instances the femur becomes dislocated upon the dorsum of 
the ilium, or even forwards upon the pubis, or upon the thyroid fora- 
men, or backwards into the ischiatic notch. 

In studying the phenomena of hip disease it is learned that it is of 
an essentially scrofulous character. The ulcerative changes in the hip- 
joint are progressive, destroying successively the head and neck of the 
femur, the cotyloid cavity, the cartilages, synovial membrane and liga- 
ments. Irritation is set up and sustained by these changes so that the 
muscles are excited to energetic contractions, thereby adding still 
more to the rapidity of the ulcerative destruction by pressing the 
joint-surfaces forcibly together. 

Therefore, in fulfilling the indications of treatment in hip disease, it 
will be necessary, first, to attend to the correction of constitutional 
impairment from scrofulous infection, and secondly, to separate the dis- 
eased bony surfaces by appropriate mechanical contrivances. The 
latter point, which alone concerns us here, will be considered. The 
necessity of making extension for the purpose of overcoming the 
energy of the irritated muscles, and separating the diseased joint-sur- 
faces has been long recognized, and the principle carried out in vari- 
ous ways, usually by means of different forms of couches, to which 
extending bands were attached. This mode of treatment had the 
great disadvantage of keeping the patient in a recumbent position, and 
depriving him of the benefits of pure air, change of scene, and all those 
beneficial influences flowing from out-door exercise. 



OF THE LOWER EXTREMITIES, 



339 



Fig. 278 Fig. 279. 




Dr Davis's splints for coxalgia. 



To Dr. Henry G. Davis, of New York, is due the credit of having 
first systematized the use of practical apparatus which admitted of 
effectual extension being made without 
confining the patient to recumbency. 

The apparatus of Dr. Davis, as seen in 
Fig. 278, consists of a long metallic side- 
splint, reaching from the hip to the ankle, 
consisting of two sections, which are mova- 
ble upon each other by means of a key. 
"To the upper end of the splint a pero- 
neal band is attached, formed of two 
bands of a length, width, and strength 
varying according to the size of the ap- 
paratus, and the circumstances of its 
application. One band is longer than 
the other, and inelastic, being made en- 
tirely of strong cotton or linen webbing; 
the other is, as it were, an oblong bag of 
India-rubber webbing (formed of sewing- 
two strips of rubber webbing together), 
filled with sawdust, tipped at each end 
with some of the inelastic webbing. 
While the inside elastic band keeps up 
the extension required, the inelastic sus- 
tains any weight that exceeds the extend- 
ing force as then applied to the patient. It is this arrangement that 
enables the weight of the body to be borne without harm, as in walk- 
ing, and that prevents injury from excessive weight or pressure upon 
the articulating surfaces in cases of accident. Thus, for instance, the 
head of the femur would, in walking, be violently thrust upwards, as 
the elastic band would yield to an increased weight, were there no in- 
elastic, unyielding band to prevent it; yet, it is obvious that this 
inelastic band does not interfere with the predetermined amount of 
tension to be exerted by the elastic one. (This amount of extension 
is determined and regulated as follows : Buckle the two bands un- 
equally, *. e., let the loop formed by the outside band be longer than 
that of the inside, and attach a weight to the latter. The number of 
pounds requisite to stretch the one loop to the exact length of the 
other represents the amount of extending force the instrument will 
exert, when exactly thus buckled, when applied upon the limb. 

"I will add, that here the amount of extending force should be 
ascertained in every instance before fastening the splint upon the 
patient; this amount is not to be varied by altering, by means of the 
saw, the length of the instrument, but by adjusting the two bands.)" 
Dr. Davis says that the long splint is best adapted to the majority 
of cases. Some years ago he was in the habit of applying a shorter 
one, seen in Fig. 279, to the femur alone. This leaves the knee at 
liberty, and in so far is an accommodation to the patient, but other- 
wise is not so effectual. 

In applying the splint " cut from a piece of adhesive plaster, spread 



340 APPAKATUS FOR REMEDYING LOSS OF SYMMETRY 




Davis's short 
splint for coxal- 
gia. 



Fig. 280. on twilled goods, and kept until the oil entering its 
composition has become oxidized, two strips from one 
and a quarter to one and a half inches wide, of the 
length of the limb from the pubis to the malleolus, and 
two strips a little narrower in proportion to the others, 
but one and a half times as long. Fold about an inch 
and a half of one extremity of each of the first cut 
strips upon itself, the adhesive sides to each other, and 
apply one on the outside and one on the inside of the 
limb, commencing with the folded end about two inches 
above the outer and inner malleoli, and extending it up 
in a straight line. 

" The other two strips are applied spirally around the 
limb as follows : Commence on the lower or folded ex- 
tremity of the straight strip above the outer malleolus, 
and wind around in front and back, so that the two 
spiral strips meet in front, a little distance above the patella. Next, 
sew a piece of firm, inelastic (linen or cotton) webbing, about one and a 
quarter inches wide and six to eight inches long, 
to the lower extremity of each straight strip, tak- 
ing particular care to include in the attachment 
the ends of both spiral strips above the external 
malleolus. The limb is then closely and firmly 
enveloped with a common roller bandage, from 
the foot upwards, the pieces of webbing only 
being left outside free. Now buckle the ankle 
portion of the splint upon the external face of 
the limb by means of the webbing ; protect the 
skin of the groin and parts to be covered by the 
perineal band by a piece of old, soft napkin, or 
table linen, several times folded and secured by 
a few stitches; and having previously adjusted 
the two bands composing the perineal band, as 
already mentioned, fasten the latter around the 
thigh, always taking care to have the buckle on 
the pelvic portion of the splint in front; the 
screw of the splint regulates its length, so that 
the required amount of extension can be secured. 
When all is correctly arranged, and proper ex- 
tension made, the upper extremity of the splint 
should fall just below the crest of the ilium." 

Dr. Lewis A. Sayre, of New York, has modi- 
fied Dr. Davis's splint ; he adds an inside splint, 
which is connected with the external one by a 
metallic stem arching across the limb ; by this 
means extension can be made with adhesive 
strips applied upon both sides of the leg. 
Mr. Eichard Barwell, of London, has also carried out the principle 
of extension in the treatment of coxalgia by the ruder splint seen in 
Fig. 282. It is sufficiently simple to be extemporized by the surgeon 




Davis's splint applied. 



OF THE LOWER EXTREMITIES. 



341 




Barwell's splint for coxalgia. 



without the aid of a mechanic, and it will, 
therefore, prove of service where the more 
elegant and efficient apparatus of Drs. Davis 
and Sayre are not at hand. 

Mr. Barwell says that "the principle of 
its construction is to make a strong India- 
rubber spring, or accumulator, act as both 
extending and counter-extending force. 
For this purpose it is fastened by each end 
to a piece of catgut that plays round pul- 
leys, attached to either end of the splint. 

" The splint seen in the figure, though 
specially arranged for the hip, with suit- 
able modifications may very easily be ap- 
plied to any joint. 

" A long Desault's splint is furnished at 
its upper part with a wire pelvic belt and 
a loop of strong wire, or of steel, which 
carries a small pulley, and which projects 
outwards about an inch and a half. The 
lower part is provided with a bar running 
across the space of the notch, and also car- 
rying a pulley. From the lower end of the 
splint, projecting inwards an inch or an 
inch and a half, is another loop, carrying a 
third pulley. A perineal band, passing round the upper part of the 
limb and splint, has a piece of rather thin catgut (violin string A or D) 
attached to it, which going through the upper loop of wire runs round 
the pulley, is brought down on the outside of the splint, aDd is attached 
to one end of the India-rubber accumulator. Eound the foot and ankle 
are fastened two pieces of webbing, which lace over the instep, and to 
both sides of which is sewn tape, forming a loop below the sole of the 
foot. This tape affords attachment to another piece of catgut, which 
plays over the pulleys, in the lower part of the splint, and is tied to 
the other end of the accumulator with the fitting amount of tension." 

Adhesive strips applied to the leg may be advantageously substi- 
tuted for the webbing in making extension. 

In using the splint " the surgeon begins by applying a broad piece 
of strapping on either side of the leg, from the knee to the foot, allow- 
ing an inch or an inch and a half of the material to project below the 
sole ; he then bandages firmly to the knee. ... It is better to leave the 
patient some hours before any force is exerted on the strapping, that 
it may establish strong adherence. When it is supposed to stick suf- 
ficiently firm, the splint is to be placed in position ; the upper portion 
will pass round the pelvis, the lower lie along the bed, quite out of 
reach of the distorted limb. The surgeon now bandages from the 
foot to the top of the thigh, independent of the splint ; arriving at the 
latter place, he causes the bandage to pass round pelvis and thigh, 
including all the upper portion of the splint, thus fixing it with suffi- 
cient firmness. Catgut is now to be fastened to the ends of the plaster 



342 APPARATUS FOR REMEDYING LOSS OF SYMMETRY 



Fig. 283. 



projecting below the foot ; the perineal band, properly padded, is to 
be adapted, and both to be fastened to the accumulator with the proper 
degree of tension. 

" For the first ten minutes or quarter of an hour, the strain should 
be slight ; the muscles soon after its application set up a startled sort 
of resistance, which, however, soon subsides, and then the India-rubber 
is to be pulled tighter. In a few hours the foot or knee will have 
descended so much that a nurse, or some other person in attendance, 
must tighten the spring, and in from eighteen to thirty hours the limb 
will have come down, and may be bandaged to the thigh part of the 
splint. This will have t^een effected without pain or violence ; indeed, 
the starting pains previously complained of will even abate under the 
downward traction. 

" If, however, the malposture be more fixed — that is, if the disease 
be further advanced into the second stage — the thigh cannot be thus 
drawn down without producing considerable pain ; and in such case 
it will be better to give chloroform, and while the patient is under its 
influence to draw down the limb into the proper position — namely, 
straight, and to bandage it upon the splint." 

Dr. E. Andrews, of Chicago, has constructed an apparatus in which 
extension and counter-extension are effected by an inside splint made 
of gas-pipe. At its upper end a crutch-shaped support is placed work- 
ing into the stem by means of a screw, to rest 
against the perineum and ischium ; the corners 
of the crutch bear straps which buckle over the 
hip ; the lower end of the splint is connected 
with the sole of the boot. The manner in which 
this instrument acts is sufficiently clear: the 
limb is extended by means of the screw, so that 
the joint surfaces of the hip are separated ; while 
in standing the weight of the patient's body is 
supported upon the crutch and transmitted to 
the ground by the side splint. 

Dr. Agnew, of Philadelphia, has also sug- 
gested a modification in the form of the appa- 
ratus, so that the perineal strap is done away 
with, and the weight of the body is sustained 
upon the perineum and ischium by the upper 
edge of a padded thigh -piece. 

The contrivance, as seen applied in Fig. 283, 
consists of an outside metallic splint extending 
from a padded pelvic strap to the margin of the 
sole of the shoe ; it can be lengthened or short- 
ened at will, so that an appropriate degree of 
extension may be obtained upon the limb ; from 
the obliquity of the pelvic strap it will be seen 
that it simply adds to the stability of the appa- 
ratus without assisting in any degree in exerting 
counter-extension, as will be seen in the instru- 
Agaew^s apparatus or men i next to ^q described. There is also an 




OF THE LOWER EXTREMITIES, 



343 



Fig. 284. 



inside splint, constructed exactly in the same manner as the former, 
reaching from the inner edge of the shoe sole to the highest point of 
the perineum. The two splints are connected above by a well-padded 
thigh-piece, the upper margin of which should 
reach well up behind, as shown by the dotted 
lines in the figure, to press against the ischium; 
a second strap encircles the leg just below the 
knee. 

The manner of fitting the thigh-piece beneath 
the buttock is seen in Fig. 284. It is exactly the 
same plan that has been pursued in the adapta- 
tion of the bucket of an artificial limb. 

Another efficient instrument in the treatment 
of coxalgia will be found in the one of which 
the accompanying wood-cuts are illustrations 
(Figs. 285 and 286). 

It is so constructed that the counter-extension 
or counter-pressure is divided between the elastic 
perineal strap, such as is used in Davis's splint 
above described, and a broad, padded pelvic 
strap ; the latter portion, besides, confers greater 
firmness and stability upon the apparatus. The 




The same, posterior view. 



Fig. 285. 



Fig. 286. 





Apparatus for coxalgia. 



The same applied. 



344 APPAEATUS FOE REMEDYING LOSS OF SYMMETEY 



outside rod extends from the pelvic belt, to which it is attached by a 
ginglymoid joint, to the outer margin of the sole of a laced boot. This 
rod is made in two sections, movable upon each other, so that it can be 
elongated or shortened. An inside splint stretches from a correspond- 
ing point upon the internal margin of the sole of the boot to the mid- 
dle of the thigh. The two rods are connected together by two well- 
padded metallic straps, one above and the other below the knee. The 
elastic perineal band is connected to the external splint by means of a 
small curved metallic stem, articulated with it in the same manner as 
in Dr. C. F. Taylor's modification of Davis's splint. 

The mode in which this apparatus is applied is seen in Fig. 286. 

It is necessary, in overcoming the contraction of the muscles, that 
the extension should be continual, and therefore, when the splint is 
not upon the patient's person, a weight, passing over a pulley at the 
foot of the bed, should be hooked to the extending band. 

In the early stage of coxalgia, when there is no abnormal contrac- 
tion of the muscles nor deformity of the limb, the application of the 
wire splint, seen in the annexed drawing (Fig. 
287), will be found advantageous. It incloses Fig. 288. 

the diseased hip and the corresponding thigh 
and leg, securing perfect immobility of those 
parts without interfering with the movements 
of the rest of the body, which is an advantage 
of no small importance in relieving the patient 
of much of the physical restraint and injurious 
influences of a protracted recumbency imposed 

Fig. 287. 





Wire splint for coxalgia. 



Mode of applying the wire splint. 



by some of the couches and apparatus sometimes employed in the 
treatment of this disease, while at the same time it secures all the 



OF THE LOWER EXTREMITIES. 345 

good that can be conferred by them. The manner in which this splint 
is applied is very well shown in Fig. 288. 

When the wire splint is not attainable, a less elegant, but yet no 
less efficient splint, may be prepared with plaster of Paris in the man- 
ner described under the section treating of fractures ; and in several 
cases in which I have employed it, entire satisfaction was obtained. 
Gutta-percha and pasteboard may also be used for making the splint. 



PART III. 

FRACTURES: THEIR REDUCTION, DRESSINGS, AND 
APPARATUS. 



CHAPTER I. 

GENERAL CONSIDERATION OP FRACTURES. 

Fractuke may be defined to be a solution of continuity of a bone 
resulting from external violence or muscular action. 

Up to the age of twenty-one, and even later, before ossification has 
been completed, the epiphyses may be separated from the shafts of 
the long bones, constituting what is called a " diastasis," which re- 
sembles fracture so closely in its causes and symptoms that it would 
be doing considerable violence to pathological analogy to consider 
the two injuries separately. 

Classification. — When a bone is broken into two pieces, the 
fracture is said to be simple; when into more than two pieces, mul- 
tiple or comminuted. A broken bone, communicating exteriorly 
through a wound, constitutes a compound fracture ; a complicated frac- 
ture is accompanied with a dislocation, rupture of bloodvessels or 
nerves — or, indeed, with any other unusual and severe injury. 

The terms complete and incomplete refer to the fact of the fracture 
running either completely or partially through the bone. 

The line of fracture may pass through the bone parallel with its 
axis, at right angles to it, or in a direction between these two ; this 
establishes a further division of these injuries into longitudinal, trans- 
verse, and oblique fractures. There are a few recorded' examples of 
perfect longitudinal fractures, and they are generally the result of a 
gunshot. In other instances they are always accompanied with one 
of the other varieties. 

In old persons, and those with very brittle bones, a transverse frac- 
ture may be encountered, though it will generally be accompanied 
with some little obliquity, yet not sufficient to permit the ends of the 
bone slipping beyond each other and overlapping. 

Thus it appears that oblique fractures are, by all odds, the most 
common, and are those always observed in healthy and vigorous 
persons. 

Occasionally it happens that one extremity of a fragment has inden- 
tations upon it which receive corresponding elevations upon the face 
of the other, forming what has been called a serrated fracture. 



CAUSES OF FEACTUEE. 347 

An impacted fracture results from one fragment being driven into 
the other and remaining fixed. 

Malgaigne has proposed the introduction of the terms single and 
multiple to express the number of pieces into which a bone is broken. 

Frequency. — The bones are not all equally liable to fracture ; the 
clavicle suffers more frequently than any other in the proportion, 
according to the statistics of Malgaigne, of 360 in 900 of all kinds. 
The long bones of the extremities, particularly the upper, from their 
extended range of motion and great length of leverage presented to 
the action of external and muscular forces, are necessarily much more 
often broken than the short bones, which are at once limited in 
extent of movement, and more compactly bound together by short 
and strong ligamentous bands, and they are therefore less liable to 
suffer damage to their continuity by mechanical agencies. 

Causes. — The causes of fracture may be conveniently divided into 
the predisposing and exciting; among the former class we find those 
diseases which sap the strength and constitutional forces, producing 
alterations in the organic integrity of the bones themselves — such as 
scrofula, gout, scurvy, rheumatism, syphilis, mollities and fragilitas 
ossium, and cancer. Old age, from the changes in the relative pro- 
portion of earthy and animal constituents of bone which accompanies 
it, is also a strong predisposing cause. Sex also has a certain influ- 
ence, inasmuch as males meet with the accident more frequently than 
females in the proportion of 7 to 5; a difference, probably, depending 
upon the greater exposure of the former class of persons to the exciting 
causes of fracture in the pursuit of their peculiar avocations. On the 
other hand, aged females more frequently suffer from this accident 
than the corresponding class of males. 

The exciting causes of fracture are two, namely, external violence 
and muscular action. External violence varies in intensity from a 
force just sufficient to break the bone to that excessive degree whereby 
the bones and soft parts are crushed and mangled frightfully, as is 
exemplified in railroad accidents and gunshot wounds. 

When the bone gives way at the point where the violence is ap- 
plied, the fracture is said to occur from direct force; and from contre- 
coup } or counter-stroke, when it takes place some distance from this 
point, as occurs sometimes when a person falls from a height upon 
his feet, breaking the bones of the leg. 

A fracture may occur at any point in the continuity of the long 
bone, but most frequently it takes place in the middle third of its 
diaphysis; and more especially does it do so when the injury results 
from counter-stroke. The reason of this will be found in the fact that 
this section of the bone offers less resistance to the force than any 
other. There are other circumstances determining the point of 
breakage, such as the direction of the force, the position of the limb at 
the time of the injury, the connection of the bones with the adjacent 
parts ; and lastly, the manner in which the force is decompounded- 
and transmitted by the bones. In illustration of the last point, it may 
be mentioned that in those sections of the limbs possessed of two 
bones, the application of violence may fracture the latter at different 



348 GENERAL CONSIDERATION OF FRACTURES. 

points, the larger bone below, and the smaller one at some point ' 
above. This tact is explicable when it is considered that in the arm 
and leg the radius and tibia form the larger portions of the wrist and 
ankle-joints ; hence in falls upon the palms of the hand and soles of 
the feet, they receive and transmit a greater share of the force; 
from their size not being able to yield sufficiently rapid to the violence 
from below, this accumulates at a given point above the ankle and 
wrist, and a fracture ensues ; the ulna and fibula, on the other hand, 
receiving and transmitting a less amount of force from their slighter 
connections with the joints, and yielding more rapidly than the large 
bones, do not give it a chance to accumulate sufficiently to damage 
them until it reaches a higher point, where the break will occur. 

"Violent muscular action less frequently determines fracture than 
external violence, and it is principally observed in the olecranon, 
patella, and os calcis. Malgaigne denied that muscular action alone 
was ever an efficient cause, in the long bones, without previous disease 
of their structure; but the recorded cases of such injuries prove irre- 
fragably that this has occurred, not only in the humerus, maxilla, 
radius, ulna, and bones of the leg, but even in the femur — the largest 
and strongest long bone of the skeleton — without any precedent 
disease whatever. Though it can scarcely be doubted that in a 
majority of such cases the broken bones will be found to have under- 
gone more or less morbid change of structure, so as to become brittle; 
this fact will also explain why it is that most of the fractures from 
muscular force approximate more or less to a transverse direction. 

Some of the congenital cases of fracture have been attributed to the 
violent contractions of the uterus during parturition. 

Symptoms. — It is very important that the practitioner should study 
accurately the symptoms which announce and accompany fracture, 
for upon such knowledge the correct diagnosis of the case will depend ; 
they are crepitus, preternatural mobility, deformity, deprivation of 
natural function, contusion, pain, and some constitutional disturbance. 

Crepitus. — This is the peculiar sound produced by the rubbing 
together of the opposing fractured ends of a bone ; it will be most 
evident in those cases where the fragments are not displaced, and are 
surrounded by a slight thickness of soft parts. Should the ends be 
impacted or overlapped, crepitus will not be heard at all, though in 
the latter case it may be developed by extending the limb. The mode 
of eliciting this sound, commonly adopted by the surgeon, is to seize 
the fragments in both hands and move them in opposite directions ; in 
the thigh, the surgeon sometimes directs an assistant to rotate the limb, 
while he brings his ear near the seat of injury. These measures, as 
indeed in all other manipulations in fractures, should be accomplished 
with the greatest gentleness. Though crepitus may generally be both 
heard and felt, yet there are cases in which the surgeon is compelled 
to depend upon the latter sense alone ; the impression communicated 
to the touch by crepitus may be obscure, yet with a little practice it 
may be discriminated from that produced by the rubbing together of 
cartilages or surfaces roughened by deposited lymph. 

Preternatural Mobility. — This is observed when a bone is broken 



SYMPTOMS. 319 

clear through, and its ends not entangled with each other ; if the limb 
is raised, that portion of it below the fracture may be moved freely in 
every direction. It will be evident, more or less, from the beginning 
of the injury to the time when consolidation of the fragments is about 
occurring. Preternatural mobility may also be present in dislocation 
in which there is extensive laceration of the ligaments, but may be 
distinguished from that of fracture by the characteristic symptoms of 
dislocation which accompany it. 

Deformity manifests itself in several modes ; when there is an over- 
riding of the fragments the limb will be shortened to an extent varying 
from one inch to three and a half inches, the average, perhaps, being 
about an inch. In impacted and partial fractures, particularly the 
latter, shortening may not be at all apparent; we may also mention 
those cases in which the line of breakage is so nearly transverse that 
the ends of the bone remain in contact. The shortening in fracture 
can almost certainly be diagnosticated from that encountered in dislo- 
cation by the fact that in the former case moderate extension causes 
the deformity to disappear, and as soon as the force is withdrawn the 
shortening recurs ; exactly the reverse is generally true in dislocation. 
The causes of shortening are, first, the violence which produced the 
injury driving the ends of the pieces of bone past each other; 
secondly, muscular contraction, which brings about the same result 
more constantly, and against which art has most to struggle in 
opposing deformity, while the patient progresses to convalescence. 

The limb may also be curved or angular at the point of fracture 
by the lateral displacement of the fragments, and indeed there may 
be actually a doubling of the limb upon itself, as I saw in several 
cases during the rapid transportation of the wounded after a disas- 
trous repulse in attacking a fort. 

Another form of deformity results from the rotation of the lower 
fragment of a broken bone upon its axis, which is so frequently seen 
in fractures of the femur in consequence of the weight of the limb 
below the point of injury. 

Deformity may occur immediately upon the infliction of the vio- 
lence or after the lapse of several days. 

Deprivation of Natural Function. — It may be readily conceived that 
a patient with a fractured limb may not be able to raise it, or to sup- 
port the weight of the body upon it, since the bones cease to furnish 
that powerful leverage indispensable to the muscles in the exercise of 
their functions; besides, the muscles are generally so much bruised 
and sore that a patient cannot often summon the required amount of 
courage to make such efforts. This loss of function, though a striking- 
feature of fracture, is yet not invariably present ; the fragments may 
be impacted when the injury occurs in the neck of the femur, or only 
one of the two bones composing the leg may be broken, in which 
instances a person may be able to walk some distance, and it is even 
stated that when both the tibia and fibula are broken progression 
may not be impossible. In the case of fractured clavicle a person 
can perform the movements of circumduction and place the hand 
upon the top of his head. 



350 GENERAL CONSIDERATION OF FRACTURES, 






Contusion. — In all cases of fracture there is more or less contusion of 
the soft parts, producing rupture of the bloodvessels, and subsequent 
effusion of blood, followed by inflammation, swelling, and effusion of 
serum. These concomitants sometimes render the diagnosis difficult, 
if not impossible, by preventing the fingers of the surgeon coming in 
sufficiently close proximity with the bone to ascertain its condition. 

Pain. — This symptom is rarely absent in any case of fracture, and 
is commonly felt at the seat of the injury; it is aggravated by pressure 
or the slightest movement of the limb, and in nervous subjects is not 
unfrequently accompanied with spasmodic action, which entails often 
the most horrible suffering upon the patients. The cause of pain is 
the tearing or bruising of the soft parts, and consequent laceration of 
their nervous filaments by the broken ends of the bone. From the 
concussion of the nerves a numbness is produced at the seat of the 
injury, and in some cases the whole limb may suffer in the same 
manner, or a patient may complain of numbness over the entire body, 
either at the time of injury, or after the lapse of several days. 

Constitutional Disturbance. — The constitutional disturbance following 
fracture varies with the violence of the injury and the extent of damage 
done the body, from a scarcely noticeable febrile movement to great 
nervous perturbation and excessive febrile reaction. 

Diagnosis. — Fractures have been confounded with sprains, disloca- 
tions, several diseases of the joints, necrosis, and caries. Should the 
injury be located near the diaphysis of a bone, the diagnosis will 
generally be easy; while, on the other hand, when it is near the joints, 
there is often great difficulty encountered ; it is in such cases that 
the greatest experience and skill are necessary to rightly elucidate 
the nature of the injury. In all cases the practitioner will require a 
thorough knowledge of the above detailed symptoms, which, taken in 
connection with other circumstances, such as the history of the case, 
age of the patient, mode in which the injury was inflicted, &c, will 
enable him to come to a correct decision. 

Prognosis. — The surgeon should be governed in his prognosis of 
a case of fracture by the knowledge he has of the amount of injury 
inflicted upon the soft parts ; whether the fracture is simple or com- 
pound, or complicated with rupture of bloodvessels, of nerves, or of 
tendons; any of these conditions rendering the case much more serious. 
A partial or an impacted fracture is more favorable for the ultimate 
restoration of the function of a limb than the other varieties ; so a 
transverse fracture will heal with less deformity than an oblique one. 
The prognosis will be more grave the nearer the injury is to the 
larger joints ; fractures of the upper extremities unite more quickly 
than those of the lower. Young and healthy persons recover more 
frequently and rapidly than those broken down by disease, intem- 
perance, and age. 

Mode of Eepair of Fractures. — The recuperative efforts of na- 
ture proceed in the repair of broken bones in the same manner as 
they do in that of the soft tissues, modified of course to some extent 
by the peculiarity of their composition in containing such an abun- 



MODE OF REPAIR OF FRACTURES. 351 

dance of the calcareous salts. There may be an effusion of plastic 
matter around the ends of the bone, which is subsequently converted 
into bone, or the consolidation may occur by a process analogous to 
that of immediate union. The mode pursued will, in a considerable 
degree, depend upon the relations of the ends of the broken bone to each 
other, their mobility, the extent of the complications of the injury, and 
whether the injured bone is shut in from the air or not. According to 
the investigations of Mr. Paget, of London, the old views of Dupuytren, 
that a provisional and definitive callus were necessary and always 
present in the course of the healing, are no longer tenable. In a few 
exceptional cases no callus is formed, nor even lymph thrown out, 
but the bone appears to unite immediately by the re-establishment of 
the continuity of the bony fibres and bloodvessels. The reparative 
process does not begin before the eighth or twelfth day after the in- 
jury; during this period of apparent rest the inflammation diminishes, 
any effused blood which may have been poured out among the tissues, 
and which rarely takes any share in the healing, is gradually absorbed, 
and along with it, in the most favorable cases, the inflammatory lymph 
also disappears. At the expiration of the above stated time, when 
these fluids have been more or less cleared away from the neighbor- 
hood of the fracture, the proper reparative materials are extravasated, 
by the organization of which the reunion of fractures is commonly 
effected. This plastic matter does not appear to differ from the ma- 
terial furnished for the healing of the tendons subcutaneously. It is 
a "structureless or dimly-shaded granular substance, like fibrin; or 
perhaps, at a later period, it is ruddy, elastic, moderately firm, and 
succulent, like firm granulation substance." This matter is placed in 
various positions as regards the broken ends of a bone, but two prin- 
cipal modes have been observed : first, it incloses them like a ferule, 
and is then called the provisional or external callus, and by Mr. Paget 
the ensheathing callus ; secondly, the matter is laid between the sur- 
faces of the bone in contact with each other, or in the angle formed by 
one fragment overhanging the other, when it is named the intermediate 
callus. The former plan is rarely observed in the human subject, 
except in those bones, such as the ribs, which must necessarily be in 
continual motion, and also in children, in whom it is difficult to keep 
the limbs quiet during the period of ossification of the broken bone ; 
while it is the common mode of repair in animals. The callus usually 
extends about a half inch above and below the plane of fracture, and 
presents a constricted appearance about its middle. It commonly lies 
between the bone and periosteum, raising that membrane from contact 
with the surface beneath. 

The interior callus fills up the cells of the medullary canal, extend- 
ing above and below the plane of fracture a distance somewhat short 
of that of the external callus. When the callus is well formed, the 
bone may be restored to its former usefulness, although its walls yet 
remain ununited, which requires a lengthy period, perhaps as much 
as eight months in a long bone ; and not until the expiration of this 
time are the materials, that have gone to form the callus, absorbed, 
leaving the surface of the bone smooth and uniform. 



352 GENERAL CONSIDERATION OF FRACTURES. • 

The second plan of union, or that by an intermediary callus, is the 
one commonly observed in man ; the reason of this is to be found in 
the fact that the fractured limbs of persons, with the exception noted 
above, are kept in greater quietness during their care than can be 
obtained in inferior animals. An additional reason is, that man pos- 
sesses a much less disposition to ossific formation than animals. 
The reparative matter is not only deposited between bony surfaces in 
contact, but it may extend also between those separated by a con- 
siderable interval. 

The process of ossification may take place in one of three manners. 
That commonly observed in adult long bones, in favorable cases, is 
by means of a nucleated blastema, a sort of rudimental fibrous tissue. 
In compound fracture the new bone may be formed by ossification of 
the nucleated cells of the granulations. In other instances the repa- 
rative materials may pass through an intermediate state either of car- 
tilage or of fibrous tissue; the former plan being sometimes observed 
in children, but rarely in adults; and it appears to be the common 
mode of ossification in animals. 

In whatever manner ossification may take place, by a subsequent 
process of absorption the injured bone is modelled, as it were, into its 
normal shape; its exterior surface is bevelled and smoothed, while 
the cells of the cancellated structure are cleared of the interior callus, 
until they form the natural and continuous medullary structure of 
healthy bone, shut in by the new walls of compact tissue. 

The periods occupied by these several parts of the reparative pro- 
cess have not, as yet, been accurately determined, but the following 
may be regarded as approximations to the truth: Eight or ten days 
elapse before the proper materials are poured out; from that time to 
about the twentieth day these become converted into a fibrous or car- 
tilaginous condition, when bone begins to appear, and continues to be 
deposited until ossification is complete, which, though exceedingly 
variable as to time, is rarely less than sixty or seventy days. 

Ununited Fractures. — From constitutional or local causes the 
process of repair may fail, and the fragments of bone will not be 
united at all, or perhaps by a fibrous or fibro-cartilaginous tissue, 
forming what has been called a pseudarthrosis, or false joint. The ends 
of the bone will generally be found rounded off] and covered with a 
layer of dense fibrous tissue, or a cartilaginous incrustation, consti- 
tuting a structure somewhat analogous to a joint ; sometimes there is 
a bursal sac developed between the bones. In other cases, instead of 
a false joint being formed, the whole of the diaphysis of the bone may 
be absorbed. 

Treatment of Ununited Fracture. — In this place the apparatus only 
which have been found useful in the treatment of false joint will detain 
us, inasmuch as the various surgical procedures of seton, cauterization, 
acupuncture and resection, are more properly treated of in general 
works on surgery. 

The common object of all bandages or apparatus, in these cases, is 
to make pressure upon the broken extremities of the bone, and to sup- 
port the limb rigidly, so as to cause a sufficient amount of irritation 



MODE OF REPAIR OF FRACTURES, 



353 



about them as to lead to an ossific deposition in the false joint. The 
compression may be effected by some of the apparatus to be de- 
scribed further on; the main point to be attended to is, that the 
pressure shall be firm, continuous, and uniform. 

For ununited fracture of the lower extremities, Prof. Henry 
Smith, of this city, has recommended the apparatus seen in Fig. 289. 
It consists of two metallic side rods, the outer one extending 
from the shoe to the hip, and the inner one reaching to the peri- 
neum, connected together by long thigh-splints, straps and buckles. 
The rods are provided with joints at the hip, knee, and ankle; a 



Fig. 289. 



Fig. 290. 





Smith's apparatus for ununited fracture of 
the femur. 



Smith's apparatus for ununited fracture 
of the leg. 



pelvic strap is connected with the upper extremity of the outer rod. 
When the apparatus is applied, the patient is enabled to take out-door 
exercise, which will materially contribute to a successful issue. Of 
similar construction is Dr. Smith's apparatus for ununited fracture of 
the leg (Fig. 290). It possesses the same advantages as the previous 
instrument in sustaining the fragments of the bone immovable, while 
the patient bears his weight upon the limb, and moves around in the 
open air. 

Both of these are elegant contrivances, and of real utility in the 
treatment of ununited fracture; they deserve a continuous and faithful 
trial before any severe surgical procedure shall be had recourse to 
to effect the consolidation of the fracture. 

In absorption of the diaphysis of the bone, an apparatus taking its 
bearings above and below the point of fracture, by means of two cir~ 
23 



354: GENERAL CONSIDERATION OF FRACTURES. 

cular and well-padded metallic straps connected laterally by two side 
rods, may be employed with advantage; in the arm, for instance, the 
"upper strap may be applied below the shoulder, and the lower one 
just above the elbow, while the side-rods will retain them sufficiently 
far apart, and at the same time give enough rigidity to the limb to 
enable the extensor and flexor muscles to act to an advantage. 

Sometimes, from bad treatment or other causes, the pieces of bone 
may unite at an angle, or in such a manner that deformity will follow. 
In this case the judicious use of mechanical contrivances will accom- 
plish a great deal in restoring the limb to its proper shape and useful- 
ness. An appropriate instrument in such instances has already been 
described in Part II. The principle involved in its use is to bring 
direct pressure upon the top of the arch formed by the crooked line, 
while its extremities serve as points of counter-pressure. 

Compound Fractures. — In our previous observations we have 
principally alluded to simple fractures, and it will not, therefore, be 
inappropriate to introduce a few remarks here concerning those which 
are compound and complicated. Fortunately, this class of injuries 
forms a very small proportion of those fractures the surgeon is called 
upon to treat; they are most commonly observed in the leg and 
thigh, and are often attended with violent inflammation and suppura- 
tion, demanding total abstinence from the application of apparatus in 
the beginning of the treatment; the limb being simply placed in the 
most comfortable and advantageous position upon pillows and 
cushions to facilitate the application of the dressing and the cleansing 
of the wound. The reduction should always be accomplished, if it is 
practicable, immediately after the injury; if the bone protrudes from 
the wound, an effort should be made to restore it to its natural posi- 
tion by making gentle extension; while the surgeon may facilitate the 
operation by stretching the orifice with his fingers, or a wooden spa- 
tula. When these efforts fail, then nothing remains but to enlarge the 
wound a little with the scalpel ; or, better, to saw off the projecting bone. 

Once the reduction is accomplished the wound must be brought 
together so as to exclude the air if possible, and place the injury un- 
der the conditions of a simple fracture. If the case does not do well, 
and pus forms, the wound must be again opened to permit the matter 
to have a free escape externally. 

To make gentle compression upon the parts the most elegant and 
convenient bandage is that of Scultetus ; warm or cold water-dress- 
ings may then be applied according to the feelings of the patient. 
My experience during the war with bad compound fractures led me 
to abandon almost entirely the use of cold water in these cases, for 
the reason that it appeared to lower the vitality of the parts already 
bruised, and disposed them to slough. After the inflammation has 
abated, in a few days extension may be made by a weight attached 
to the leg by two lateral strips of adhesive plaster running "up its 
sides and hanging over the foot of the bed. 

When the inflammation and suppurative action have still more 
decreased, there will be no objection to treat the case with the appara- 
tus employed in simple fracture. Indeed, in ordinary cases of com- 






GENERAL TREATMENT OF FRACTURES. 355 

pound fracture the apparatus may be immediately applied, taking care 
that the bandages be sufficiently loose to allow for subsequent swelling, 
otherwise dangerous results may occur in the shape of mortification 
from excessive pressure. 

The complications of this class of fractures are pyaemia, erysipelas, 
and tetanus, which are to be treated upon principles applicable to those 
diseases. 

Complicated Fractures. — Should a dislocation accompany frac- 
ture, every means should be safely tried to effect the reduction of the 
dislocation first, by pressing with the fingers upon the upper fragment, 
accompanying it at the same time with proper manipulation of the 
limb, which may be rendered still more manageable by fastening 
it with straps, or a roller, to a board extending beneath its whole 
length ; if these means succeed, the fracture may then be reduced in the 
usual way ; on the contrary, if they do not, the limb should be placed 
in the best possible position for union of the bone to take place in a 
right line. When consolidation has been completed, gentle attempts 
may again be made to reduce the dislocation by manipulation, but at 
this period of the case success will rarely reward the surgeon's efforts. 

The complication of rupture of bloodvessels and nerves, and exten- 
sive lacerations of the soft tissues, are to be treated by measures appro- 
priate to those injuries, the former accident requiring ligature, and the 
latter the use of sutures and adhesive strips. 

General Treatment of Fractures. — In the treatment of a frac- 
ture it should be a surgeon's first care by a scrutinizing, minute, and 
carefully conducted examination to find out exactly what the condi- 
tion of the bone may be. The greatest tenderness and expedition 
compatible with the ascertainment of the desired information, should 
be exercised, for any improper or rude manipulations not only inflict 
uncalled for suffering upon the patient, but they also materially influ- 
ence his subsequent recovery. It will be the best plan, when any 
lengthy examination is necessary, to put the person under the influ- 
ence of chloroform, which will not only obviate pain, but will secure 
the additional advantage of enabliug the surgeon to make a more 
thorough examination unopposed by the struggles of the patient or 
the contraction of the muscles. When the fracture is clearly made 
out the indications of treatment are to be fulfilled ; of these there are 
three principal ones which naturally present themselves : first, to re- 
duce the fracture ; second, to retain the fragments of the broken bone 
in a proper position after the reduction ; third, to counteract subse- 
quent complications. 

Reduction. — It was formerly a question among surgeons as to the 
proper time for reduction; whether to wait for the inflammation and 
swelling to subside before manipulative interference, or to proceed 
with the manipulation immediately. The general experience of the 
ablest surgeons in Europe and America have decided the latter plan 
to be the best, and it is the one now almost universally practised. 

The means for accomplishing the reduction are, first, extension and 
counter-extension employed conjointly ; and second, coaptation. Ex- 
tension is the force applied to the lower fragment of a broken bone, 



356 GENERAL CONSIDERATION OF FRACTURES. 

and counter-extension is the opposing force acting in exactly the con- 
trary direction ; coaptation is merely the kneading and pressure upon 
the soft parts about the injured point, exercised with a view of shoving 
the fragments into their normal situation. 

The opinions of surgeons are somewhat different as to the exact 
points to which the extending and counter-extending bands should be 
affixed. English writers commonly recommend that they be applied 
directly to the fragments themselves some distance above and below 
the place of fracture ; while the French surgeons deem it more ad- 
vantageous to place them upon those sections of the limb connected 
with the fragments above and below. 

The advocates of the first method contend that by their plan a 
more effective and direct force can be brought to bear ; while those 
of the second method, admitting the advantage gained by applying 
the bands in this manner, urge that at the same time that greater force 
is exerted, the muscles will be stimulated to stronger contractions by 
the local irritation thus caused, which will more than counterbalance 
the gain in power. 

The truth in this, as in most questions of the kind, lies midway 
between the extremes, and the judicious surgeon will use one or the 
other plan as best suits the exigencies of the particular case he is called 
upon to treat. During the efforts at reduction the limb should be 
held in that position which most thoroughly relaxes those muscles 
opposing the replacement of the fragments in their normal situation ; 
usually one of moderate flexion will be found the best. 

The two forces, extension and counter-extension, should at first be 
made in the direction of the axes of the fragments upon which they 
act ; that is, in the direction of the displacement ; when the ends of the 
bone are in this manner disentangled the forces must be brought to 
bear in a straight line until the reduction is accomplished, which 
should be furthered by pressing with the fingers upon the displaced 
pieces. 

If the fracture is transverse, it can readily be imagined how the 
reduction may be effected and consolidation of the bone obtained 
with little or no shortening of the limb ; but the case is different in 
oblique fracture in which it is almost impossible by any manipulation 
to bring the fragments into exact contact, and sustain them until the 
repair is effected, without more or less shortening. In fifty cases of 
which I have notes, of gunshot fracture of the long bones, the shorten- 
ing varied from one inch the minimum, to four and a half inches the 
maximum. The next object after the reduction has been accom- 
plished, is to maintain the fragments immovable until union occurs. 
Opinions of surgeons as to the best position in which the limb should 
be placed to secure this result have varied. The straight posture was 
recommended by Hippocrates and generally practised by surgeons 
until the eighteenth century, when Broomfield and Pott advised and 
practised the plan of keeping the limb flexed. The former method 
has met with many able supporters, both in Europe and America, and 
in the latter country I believe it is most commonly pursued, except 
in fractures of the lower third of the femur. These remarks, of course, 



GENERAL TREATMENT OF FRACTURES. 357 

apply to fractures of the lower extremities ; for, perhaps, with the ex- 
ception of fracture of the olecranon, all injuries of this kind in the 
upper extremities are treated in the bent position. From a remote 
period surgeons have sometimes employed certain mechanical con- 
trivances or machines to effect reduction, such as the bars of Hippo- 
crates, the plinthium of Nileus, the glossocomes of Galen and Pare, 
and in later times the adjuster of Jarvis, but in this class of injuries 
these are entirely unnecessary, inasmuch as no greater amount of force 
is required than can be exercised by the natural powers of the surgeon 
and of his assistants. 

Retention. — There are great difficulties encountered in fulfilling the 
second indication ; position will accomplish something, but the greatest 
dependence must be put upon properly constructed appliances, of 
which there are a great many varieties. There is perhaps no branch 
of surgery in which more genius has been displayed in invention than 
in this one, and it will, therefore, be proper to devote some space to 
a consideration of the general features and character of the apparatus 
that are now employed. 

Splints are the most indispensable and important means used in the 
treatment of fracture. To adapt them to the great variety of injuries 
of this nature occurring daily, they are required to be made in vari- 
ous forms, of different sizes, and of several materials. 

"Wooden splints, of all others, from their general utility, efficiency, 
accessibility, and simplicity of construction, have always and do now 
enjoy the largest share of professional patronage, and this is truly well 
deserved when we consider the ease with which any person may, with 
a knife and a piece of soft white pine, linden, or any such light strong 
material, prepare splints well adapted to the treatment of most any 
case of fracture in which splints are needed. An additional recom- 
mendation is, that these materials may be obtained without cost, and 
are to be found very conveniently at hand. 

In these encomiums we do not wish to be understood as including 
those carved splints furnished by surgical instrument-makers and 
bandagists; but should this description of splint be desired, the 
surgeon should superintend its construction in order that it may be 
adapted to the case in which it is to be used, for it would rarely 
happen that any one of these contrivances would possess that form 
and size adapting it to the treatment of a case for which it was not 
made. 

As to the matter of form, splints vary : some are straight, as those 
of Desault for fracture of the femur; some angular or curved, as 
Physick's splint for the elbow ; others are shaped to resemble the out- 
lines of the part to which they are applied, as Pott's splint for fracture 
of the leg, the palette, and foot-board ; while a third class are grooved 
in various degrees to fit the irregularities of parts. Splints may also 
be entire, or notched or perforated to enable the turns of the roller or 
other fastenings to be more effective in holding them to the limbs. 

The size of splints is a matter of importance both as regards their 
neat appearance and effectiveness; for when they are clumsy the 
general appearance of the dressing will be marred and they cannot be 



358 



GENERAL CONSIDERATION OF FRACTURES. 



so securely or accurately fixed to the parts beneath. Those materials 
should be selected which, when reduced to the lightest and thinnest 
laminae possess a sufficient degree of toughness and strength to main- 
tain the limb immovable ; the thinnest splints need rarely to be less 
than one-sixth of an inch nor the thickest more than three-eighths of 
an inch upon their edge. Their width should be sufficient, as a general 
rule, to prevent the bandage pressing upon the edges of the limb 
between them ; which might displace the fractured bone ; a result that 
has not unfrequently happened in putting splints on the forearm. 
Their length is also to be carefully attended to ; in fracture of the 
lower part of the fibula and of the upper third of the humerus, if the 
splints are too short, as I have seen them applied, they do not serve 
the purpose for which they are intended. 

Besides wood, splints may also be made of horn or whalebone, or 
the tough inner bark of various trees, which, when dipped in hot 
water are susceptible of being moulded to the limbs with accuracy. 
In cases of emergency, the flexible twigs of trees, thin reeds or straw 
rolled up in a piece of cloth, will also supply good splints. 

Pads are usually prepared for splints of chaff or bran, inclosed in 
sacks of the proper length and width ; these materials make cooler 
and more easily adaptable cushions than wool or curled hair, which are 
sometimes used. Another convenient and neat plan is to inclose the 
splint in a little sack, leaving one of its ends open, through which cot- 
ton-batting is stuffed, until a sufficiently thick cushion is obtained 
upon one side of the splint, when the mouth of the sack is sewed up. 
A more expeditious method still is to lay the cotton-batting upon a 
splint and inclose them both with a roller bandage. 

M. Grariel has recommended the employment of air-cushions, made 

of India-rubber, which may be inflated through a tube connected with 

them to the desired extent. Fig. 291 shows these pads 

Fig. 291. separated from the splints. Fig. 292 represents the 
cushions connected with the splints, and applied. 

Pasteboard is a cheap, efficient, and widely diffused 
substance, to be found in every house in some shape or 

Fig. 292. 





Air-cushions for splints. 



The same applied. 



other, paper boxes, bandboxes, etc., and is well adapted to the prepa- 
ration of splints. It is thrown into commerce by the manufacturer, 
made of different sizes, from No. 1, the frailest, to No. 10, the stoutest 
article ; for the lower extremities No. 7 will be sufficiently stiff to 
make splints of; and for the upper extremities No. 4 or 6. 

The method of preparing these splints is altogether simple, and 



GENERAL TREATMENT OF FRACTURES, 



359 



with a little experience a very good mould of any portion of the body 
may be obtained. The pasteboard is dipped in hot water until it is 
sufficiently soft to be moulded to the surface, to which it is confined 
by a roller bandage ; when nearly dry the pasteboard is removed, and 
properly trimmed by a pair of shears, or, better, by the instrument 
invented by M. Seutin for this purpose (Fig. 293). 

Fig. 293. 




Seutin's pliers. 

To make the most perfect models in pasteboard M. Mercie (Mercie, 
Appareils modeles, ou nouveau systhne de deligation, Gand, 1858) has 
proposed to obtain an exact pattern of each extremity by projecting 
upon a flat ground those curved surfaces which determine its out- 
ward configuration; for instance, in procuring a projection of the 
lower extremity he selects a person of average stature, and applies a 
roller bandage from the toes to the groin, where a spica is formed, a 
solution of starch is smeared over this, and a second roller is laid on in 
the same manner as the first, then more starch. When the bandage is 
quite dry it is removed by an incision extending from a point midway 

Fig. 294. 




Horizontal projection for making splints for the thigh. 

the dorsum of the foot to the middle of Poupart's ligament ; the model 
is then moistened with a wet sponge, spread out upon a large sheet 



360 



GENERAL CONSIDERATION OF FRACTURES 



of paper, and its margins traced out with a lead pencil. A line drawn 
from the apex of the heel to a point over the ischium will divide the 
bandage into an external and internal splint ; if a piece two inches 
wide be cut from the middle of each of these, four splints will be 
formed, two for the thigh, and an equal number for the leg, so that 
they may be used singly or combinedly, according to the judgment of 
the surgeon or the necessities of the case. In the same manner, a pro- 
jection may be made of the upper extremity. Now, from the hori- 
zontal projection, or outlines traced upon the paper, any number of 
splints may be proposed. Fig. 294 shows the projection of the thigh ; 
the external splint for a person of average height will measure in its 
perpendicular twenty-five inches, and the inner one seventeen inches ; 
for heights above and below this it is only necessary to increase or 
diminish the paper pattern with the scissors. 

Fig. 295 shows a projection of the leg; the length of the pattern is 
twenty-four inches. 

Fig. 295. 




Horizontal projection for making splints for the leg. 

In Fig. 296 the pattern for the arm is shown, taken from a starch 
bandage, which has been divided from the apex of the olecranon to 

the posterior extremity 
Fi S* 296 ' of the fold of the axilla 

posteriorly, and from the 
middle of the bend of the 
elbow to the acromion an- 
teriorly ; the outer pattern 
is fourteen inches, and 
the inner is eight inches 
long. 

The projection of the 
forearm is obtained from 
a starch bandage extend- 
ing from the roots of the 
fingers to the elbow, and 

Horizontal projection for making splints for the arm. ° , ., ... 

removed by two incisions, 
one along the radial, and the other along the ulnar border of the forearm; 
when these are spread out and traced upon paper, they give the appear- 
ance seen in Fig. 297, the posterior pattern being eighteen inches long, 
and the anterior one fourteen inches. 

After the pasteboard splints have been cut upon these patterns 
they are immersed in warm water, and when sufficiently soft are 




GENERAL TREATMENT OF FRACTURES, 



361 



drawn out and moulded accurately to every point of the surface 
which they are intended to cover, with the fingers ; a roller bandage 

Fig. 297. 




Horizontal projection for making splints for the forearm. 

is then applied to hold the splints in contact with the skin ; at the 
expiration of an hour or two the splints will be sufficiently dried to 
retain their shape, when they are to be removed and placed in an up- 
right position before the fire, or in a current of air to insure their 
thorough desiccation. Should any wound exist, that part of the paste- 
board corresponding with it may be first softened, and then removed 
with the shears. 




Pasteboard splints for the thigh. 
Fig. 299. 




Pasteboard splints for the forearm. 

Fig. 298 shows the appearance of splints prepared upon these 
models for the thigh, and Fig. 299 those for the forearm. They form 



362 



GENERAL CONSIDERATION OF FRACTURES. 



Fig. 300. 



accurate moulds of the limbs, and, when property padded and applied 
nothing can be better for retaining the reduction of fracture than they. 
Any fear of their strangulating the parts by inordinate pressure, when 
applied as shown below, may be entirely dispelled, inasmuch as the 
surgeon has the limb beneath his observation constantly, and can 
regulate at his pleasure the amount of pressure he designs the splints 
to make. 

The splints having been prepared, they are applied by placing 
within them layers of cotton-batting so as to form a soft bed, upon 
which the limb reposes ; a roller bandage, or a 
few strips of elastic ribbon, will suffice to main- 
tain the splints in their proper position. The 
mode of applying the apparatus is seen in Fig. 
300. 

Gutta-percha is now furnished the surgeon, 
rolled in sheets from a sixteenth to a quarter of 
an inch in thickness ; the thinner ones will be 
required in fractures of the smaller bones, while 
for the larger bones, sheets from an eighth to a 
quarter of an inch thick are necessary. Should 
the article be only attainable in masses, it may 
be softened in warm water, and made into sheets 
by kneading it with the fingers and afterwards 
rolling it out with a cylinder of wood. 

It requires a good deal of tact to make a neat 
and serviceable gutta-percha splint ; for the mate- 
rial, immersed in warm water too long, becomes 
very soft and difficult of management, sticking 
to the fingers or anything it touches. I have 
usually pursued a plan, in manipulating with 
gutta-percha, similar to that described by Dr. 
Hamilton in his Treatise on Fractures and Dis- 
locations. He says that "when constructing from 
this material a thigh-splint, we should order a 
very large tin pan, or some open flat tray, in 
which we may lay the splint at full length. If 
the splint is required to be twelve inches long, 
and six wide, we must cut it about sixteen 
inches long by eight wide, so as to allow for the 
contraction which always takes place more or 
less when the hot water is applied. It is then to 
be laid upon a sheet of cotton cloth of more than twice the width of 
the splint, in order that the cloth may envelop it completely when it 
is folded upon it; and the cloth should be enough longer than the 
splint to enable us to handle and lift it by the two ends without 
immersing our fingers in the hot water. Besides, if the gum is not 
thus covered and supported, it will adhere to the vessel, to the fingers, 
to the surface of the limb, and indeed to whatever else it may come 
in contact with ; it may even fall to pieces, or become very much 
stretched and distorted by its own weight. The cloth cover will gene- 



: 




Mode of applying a paste- 
board splint in fracture of 
the leg. 



GENERAL TREATMENT OF FRACTURES. 363 

rally adhere to the splint, and may be permitted to remain upon it 
permanently. 

"Place the splint, thus covered, in the basin, and pour on the water 
at or near the temperature of boiling. As soon as it is sufficiently 
softened, lift it carefully, and lay it over the limb, and by its own 
weight it will adjust itself to the surface, or it may be moulded with 
the hands or by pressing it against the limb with a pillow. If it does 
not harden rapidly enough, this process may be hastened by sponging 
the outer surface with cold water; and as soon as it has acquired 
sufficient firmness to support itself, it may be removed and immersed 
in a pail of cold water or placed under a hydrant ; after this, it is to 
be neatly trimmed and dried, when it is ready for use." 

Benjamin Welsh, of Lakesville, Conn., has made quite convenient 
splints by covering both sides of the gutta-percha with thin flexible 
laminae of wood; they may be accurately adapted to the surface by 
softening them in hot water. By frequent use, the wood is apt to 
separate from the gum, and the splint becomes worthless. Fig. 301 
shows Welsh's splints for the forearm. 

Fig. 301. 




Welsh's splints for the forearm. 

Very neat and strong apparatus may be prepared with paper in the 
following manner : Take of coarse, porous paper, of any kind, a large 
sheet, and, having spread it out upon a table or any flat surface, rub 
into its interstices a solution of starch, and repeat the process upon the 
other side; then cut the sheet into strips from eight to twelve inches 
long and two inches wide. To apply them, first shave the surface of the 
fractured limb thoroughly, and, after the fracture is reduced, envelop 
it in a layer of cotton-batting, which is held in its place by an assistant 
or by a few threads tied around it, while the surgeon puts on the 
starched strips from below upwards, each overlapping a third of the 
width of its predecessor, after the manner of the bandage of Scultetus, 
until the whole limb or the desired extent of surface is covered. Lay 
over these three or four vertical strips, placed at equal distances apart, 
and then another circular layer; thus alternate the direction of th'e 
strips three or four times, or until the splint shall have acquired 
sufficient strength to answer its purpose. In twenty-four hours the 
apparatus will be hard and dry, though it will be well to provide 
against possible accidents during the intervening time by applying 
two lateral splints and a roller bandage. Its removal may be accom- 
plished by dividing it into lateral or antero -posterior sections with 
Seutin's pliers. 



364 GENERAL CONSIDERATION OF FRACTURES. 

Sole-leather makes an excellent splint ; it softens readily in water, 
may be easily moulded to the limb, and, desiccating, forms a hard, 
resisting shell. The splint may be cut out of the leather upon the 
patterns already described for making pasteboard splints. After the 
action at Wilmington, N. C, I applied the leather splints to some ten 
or twelve cases of fracture of the arms and legs, with gratifying results. 

Another form in which leather is used is to glue to a sheet of 
buckskin a thin lamina of wood, and, after it is dried, the wood is 
cut in narrow strips. This makes the most unsatisfactory apparatus 
possible ; it can neither be neatly nor accurately applied to any sur- 
face, at least those that I have tried, contained in the allowance table 
of the Medical Department of the Navy. 

Felt, or any sort of old stout cloth, saturated with a solution of 
shellac, containing half a pound of this gum dissolved in a quart of 
alcohol, and dried, will also make good splints at little expense. The 
following method may be pursued in their preparation : Lay the cloth 
upon a flat surface, and with a brush give it a good coating of the 
solution, which should then be thoroughly dried in a current of air; 
after which three or four more applications may be made in a similar 
manner. The cloth is now to be folded upon itself, and pressed with 
a hot flat-iron until its sides adhere ; repeat the doublings and ironing 
three or four times, when the requisite thickness will be obtained. 

To apply such a splint, first reduce the fracture; and having soft- 
ened shellaced cloth in hot water, lay it upon the limb, previously 
swathed in a layer of cotton-batting, and press upon it with the hands 
in every direction until it is closely in contact with the surface ; then 
put a roller-bandage over it. The adjustment of this splint should be 
quickly done, as it hardens in ten or fifteen minutes. 

The " moulding tablet" is a name given by Mr. Alfred Smee to a 
contrivance of his prepared in the following manner : Take a piece of 
coarse old cotton cloth ; spread it on a table, and apply to its surface, 
with a brush, a mixture prepared by adding common whiting to 
mucilage of gum-arabic, until the latter has acquired the consistence 
of thick paste ; then double the cloth upon itself, and permit it to dry, 
when a tough, hard board will result, well adapted for making light 
and strong splints. In using them they are to be softened with hot 
water, squeezed from a sponge. 

The common glue, melted in the usual manner in a kettle, and 
when cold having about a fifth part of its bulk of alcohol added, will 
form a good elastic and durable bandage. It may be applied in the 
following manner: Envelop the limb in a layer of cotton -batting, over 
this put a roller-bandage from below upwards, which is then smeared 
with the glue; another roller is placed over this, and glued in the 
same manner as the first ; a third roller is applied, and coated with 
glue, when the dressing is finished by a bandage put over the whole. 
The limb should be left at rest from twelve to twenty-four hours, 
when the bandage will be sufficiently hard to be cut through its 
whole length, and the margins trimmed with the scissors, so that an 
interval of a quarter of an inch will be left between them. Along the 
margins holes are now to be punched, and "oeillets" inserted into 



GENERAL TREATMENT OF FRACTURES. 365 

them, through which a soft lacing cord is to be passed. In this appa- 
ratus the compression may be graduated by the cord; it is perfectly 
elastic, and may be removed from the leg with ease by simply press- 
ing its sides asunder. 

The metals used for metallic splints are iron, copper, lead, and 
zinc — particularly the former — under the forms of tinned sheets and 
wire-gauze. Of the tinned sheets, or, as it is more commonly called, 
tin, very light splints can be prepared by bending them into proper 
shape to fit the limb after having been cut roughly into the outline 
of the parts ; to confer additional lightness they may also be perfo- 
rated with holes. The proper shape is conferred upon wire-gauze by 
modelling it upon casts of the limbs in plaster of Paris or wood, and 
binding it with strong wire. The advantages claimed for splints 
made in this way are that they will permit the perspiration to escape 
freely, allow fluid applications to be made without impairing their 
stability ; and lastly, are sufficiently flexible to be closely fitted to the 
parts beneath. But these advantages are more apparent than real; 
for the cotton-batting used with most all of this class of splints will 
serve as an effective absorbent, so that no more inconvenience will 
result from the exuded moisture in using them than those made of 
wire; wire-gauze cannot be so nicely adjusted to the limbs either as 
pasteboard and leather ; and as to their permitting the employment of 
water-dressings, any other sort of splint will do the same without 
impairing its strength, if it is properly managed. There are excep- 
tional cases, however, in which they may be used with advantage ; 
for instance, in compound fracture of the elbow-joint, with profuse 
suppuration; and in gunshot wounds of this nature I have employed 
the wire splint with satisfaction. Bauer, of New York, has displayed 
a good deal of ingenuity in constructing this kind of apparatus, and it 
cannot be denied that they are gotten up very artistically; but their 
comparatively high cost, and inferiority to splints made of other mate- 
rials, will prevent them from coming into general use. 

Immovable Apparatus. — The French surgeons have conferred this 
name upon a class of splints of which we shall now speak. They 
were undoubtedly employed long ago by the Arabs, and some of the 
Eastern nations, as the writings of Ehazes and Albucasis sufficiently 
prove. It is stated that the idea of treating fracture by the immova- 
ble apparatus, in modern times, first occurred to M. Geoffroy, sug- 
gested by an examination of some ancient Egyptian relics. 

Theodoric, Lanfranc, and Gruy de Chauliac, employed this form of 
bandage; and the latter recommended the use of a mixture of various 
gummy and resinous substances in its composition. Ambrose Pare 
directed his friend Richard Hubert, who was attending him for a frac- 
tured leg, "to fortify the sides of his limbs with junks made of tents 
or little sticks, and lined with linen cloth." He also gives the fol- 
lowing formula for a mixture which " should be applied all around 
a broken leg;" frankincense, mastich, aloes, and Armenian bole, 
of each an ounce; alum and resin, of each three drachms; flour, a 
pound and a half; and a sufficient number of eggs to make a paste. 
In 1768 Moschati used compresses and bandages saturated with the 



366 



GENERAL CONSIDERATION OF FRACTURES. 



white of eggs ; and Le Dran added to these, in preparing his band- 
ages, vinegar, Armenian bole, starch, and plaster. 

After Moschati, Baron Larrey was the first to revive the use of the 
immovable apparatus, and it was the authority of his name and prac- 
tice which caused it to be generally adopted by surgeons every- 
where. The solidifying liquid used by this distinguished surgeon was 
composed of camphorated brandy, Goulard's extract, and the whites 

of eggs beaten up with water. The dressing 
Fig. 302. consisted of the bandage of Scultetus, two 

lateral splints made of unbroken straw, com- 
presses, and a splint cloth. 

This apparatus was used by Larrey, not 
only in fractures, but in severe contusions 
and wounds, and in the former case it was 
never removed until consolidation had taken 
place, unless some adverse accident com- 
pelled him to do so. 

M. Seutin (Traite de la Methode amovo-ina- 
movible, Bruxelles, 1849), Surgeon-in-Chief 
of the Belgian army, began, in 1834, to 
make trials of various solidifying liquids, 
and of these found a solution of starch to be 
the best. He at first used a contrivance simi- 
lar to that of Baron Larrey, but subsequently 
contrived a different one, which he designated 
as the "movable-immovable" apparatus (ap- 
pareil amovo-inamovible) ; he adjusted its 
several parts in the following manner (Fig. 
302) : Having reduced the fracture, and made 
the surface of the limb uniform by compresses 
of amadou or tow, he applies a roller bandage 
from the toes upwards ; reaching the superior 
portion of the member a reverse turn is made, 
and a second layer is put over the first from 
above downwards. A solution of starch is 
now smeared over the whole surface either 
with a brush or with the hand. Beneath the 
turns of the bandage along the anterior sur- 
face of the limb, and in contact with the skin, 
he places a greased cord called by him a com- 
pressimetre (compressi metre), the extremities 
of which hang externally and are looped ; by 
pulling upon these loops the amount of pres- 
sure exercised by the bandage can be ascer- 
tained. Over the roller pasteboard splints are 
laid, having been previously softened in hot 
water, thoroughly starched upon both sides, 
and accurately modelled to the limb ; while 
these are being held by an assistant he covers them with a roller band- 
age, proceeding from below upwards, and returning exhausts the roller 




Seutin's apparatus for fractures of 
the lower extremity. 



GENERAL TREATMENT OF FRACTURES, 



367 



by several turns about the foot or ankle as the case may be, taking care 
always to have the toes and ringers exposed. An additional quantity 
of starch is again uniformly distributed over the apparatus with the 
palm of the hand, and the dressing is complete. In fractures of« bones 
t of the leg, M. Seutin employs, instead of the roller form of the band- 
age of Scultetus, interposing between the first and second a posterior 
pasteboard splint, and between the second and third bandages two 
lateral splints ; all of these layers are to be starched, except the first. 
Seutin objects to placing a starch bandage in direct contact with the 
skin, as it is apt to produce irritation and possibly erysipelas. 

While the bandage is desiccating, which occupies a period from 
thirty to forty hours, he advises precautionary splints to be applied to 
the sides of the limb to sustain it. When the drying is completed, 
Seutin directs the hardened shell to be cut open along its anterior sur- 
face, using the cord previously spoken of as a guide ; the limb may 
now be inspected, and defects, if there are any in the dressing, corrected, 
such as the cording or knotting of the rollers ; unequal pressure should 
be carefully guarded against by the use of compresses, or what is bet- 
ter, cotton-batting. If everything has gone on nicely, the valves should 
be drawn together and supported by the turns of a roller, or two or 
three elastic cords encircling the limb. 

Should any wound exist, that portion of the pasteboard opposite to 
it may be removed with the scissors, having previously been softened 
with water; or, instead of removing the piece entirely, it will be better 
to let it remain as a sort of valve (Fig. 304), so that when the sore 
is dressed it may be again covered by the paste- 
board, which will prevent any bulging out of 
the tissues beneath. 

Velpeau has also used extensively the im- 
movable apparatus in the treatment of fractures. 
He employs a solution of dextrine instead of 
starch, made of the following articles: Dextrine, 
one hundred parts; camphorated brandy and 
hot water, of each fifty parts. The dextrine is 
placed in a vessel and the camphorated brandy 
is gradually added, stirring the while until the 
materials are intimately mixed and the solution 
is of the consistence of honey; the water is now 
poured in, which will render the mixture about 
as thin as a light soup when it is ready for use. 

The fracture is first reduced, and the limb 
covered with a protective bandage, when the 
roller, soaked in the solution of dextrine, is 
laid on, beginning at the extremity of the limb 
and ascending in the usual manner, taking care 
to make the requisite number of reverses that 
the bandage may not pucker. 

When the bandage formed in this manner is 
not sufficiently strong, Yelpeau introduces, like 
Seutin, pasteboard splints among its folds, having previously softened 



Fig. 303. 




Immovable apparatus with 
valve over seat of injury. 



368 GENERAL CONSIDERATION OF FRACTURES. 

them in camphorated brandy, which will hasten the drying process, 
which requires about four or rive hours. An opening may be left 
opposite any wound by leaving an interval between the turns of the 
rollers, as they are being put on. 

The quantities of dextrine used by M. Yelpeau in preparing his 
bandages are as follows : For fracture of the thigh, eighteen ounces ; 
for the leg, ten ; and for the arm, seven. It is important to obtain a 
good quality of dextrine, as a good deal of that thrown into commerce 
is utterly worthless for the purpose of preparing bandages. The sort 
that should be selected is of a yellowish color and not so crumbly 
and crepitating between the fingers as those specimens containing 
starch ; it strikes a deep red color with the tincture of iodine. 

Splints of Plaster of Paris. — These were employed long ago by the 
Moors of Spain, and by Hubenthal in 1819 ; but their first introduc- 
tion is commonly ascribed to Dieffenbaeh, of Berlin. The method was 
to surround the fractured portion of the limb with a large quantity of 
the plaster, so as to form a sort of box about it. Prepared in this way 
the splints were heavy and objectionable, inasmuch as they needed 
often to be cut away with hammer and chisel to expose the parts be- 
neath rendered tender and painful by the confined perspiration and 
by the increased heat thereby produced ; they are besides in constant 
danger of becoming constrictive to such a degree as to produce morti- 
fication, though I have seen several cases of fractured thigh brought 
to a happy issue, by the Dutch surgeons, with these splints. 

These objections do not hold against the plaster bandages now to 
be described, which have been particularly studied by MM. Mathijssen 
and Yan de Loo, of Holland, and Prof. PirogofiJ of St. Petersburg 
{Gazette Hebdomadaire, Aug. 1854). There are several methods of 
preparing them, but I have usually pursued the directions given by 
Yan de Loo, who uses either rollers or the bandage of Scultetus. To 
make plastic splints of rollers, he recommends you to "spread upon a 
table a piece of cotton cloth, free from starch and softened by use, or 
of flannel, five Teet long by a foot and a half wide ; upon this cloth 
scatter at least a pound and a quarter of very dry plaster in powder, 
which should be made to penetrate it as much as possible by stroking 
it with the open palm ; then, after having removed the excess of 
plaster, we turn the piece over, and perform the same operation upon 
the other side. Both sides of the cloth being well impregnated with 
plaster, we cut it, remaining still on the table, into strips one and 
a half or two inches wide, which can be neatly done by previously 
making grooves upon it, at equal distances, by means of a thin cord 
stretched across its surface, and which, raised with the fingers by its 
centre, is permitted to strike upon it ; then we roll them upon the 
table with much less firmness than we do ordinary rollers. The roller 
bandages keep very well, providing we place them in a tight box. 

"In order to use them, we take, if we have to do with a fracture of 
the leg, the member being previously surrounded with an ordinary 
roller bandage, one of these plastered rollers, which we moisten well 
with water, with the aid of a sponge (the water being introduced into 
both ends of the roller), and apply it as an ordinary roller, with 



GENERAL TREATMENT OF FRACTURES. 369 

this difference, that the turns should cover each other three-fourths or 
four-fifths of their width ; in the same manner we moisten and apply 
a second and a third roller, and so on, taking care to place the initial 
extremity of a succeeding one below that one applied just before. In 
this way the apparatus can be better unrolled. 

" If we do not wish to make any reverses, we cut the roller each 
time that a change of direction becomes indispensable. 

"In order to give the bandage the desirable smoothness and elegance, 
it suffices to pass lightly over its surface a slightly moistened sponge 
every time two or three rollers are applied. 

"In order to make a fenestrum, we go to work in the following 
manner : Arriving near a wound, for example, we cut the roller and 
commence upon its opposite side, and continue thus until we have 
passed beyond the wound. 

"Should we wish to render the bandage removable (amovible), we 
cut it by means of Seutin's scissors, and we obtain removable valves 
that answer special indications, which will be laid down further on. 

" Should we wish to remove it, it is well to moisten it a little, to 
prevent the liberation of the dust of the plaster." 

There are also two ways of making plaster splints with the bandage 
of Scultetus. "In the first, we arrange, in the form of the bandage 
of Scultetus, twenty-five or thirty plastered strips upon a cushion fur- 
nished with a napkin ; they should cover each other three-fourths of 
their width. Upon these we place a layer of ordinary strips, and on 
this apparatus, thus prepared, we place the fractured member. 

" After having applied the ordinary strips, we moisten, with the aid 
of a sponge, one or two plastered strips, which we apply immediately, 
and we continue thus until all the plastered strips shall be applied. 

"In order to fenestrate the bandage, or to render it removable, we 
go to work as for the apparatus prepared with the rollers." 

In the second method, " upon a cushion covered with a napkin we 
place first a plastered strip, over which we spread a strip without 
plaster, of the same width, but two fingers' width longer, in such a 
manner as to extend beyond the first a finger's width at each end, and 
with the same precaution to cause it to overlap also the plastered strip 
another finger's breadth in the direction of its width. The plastered 
strip which has the same dimensions in this direction as the strip 
without plaster will then offer a plastered border to unite with the 
other pieces of the apparatus. These first two strips being thus 
arranged, we spread a plastered strip upon one without plaster, in 
lengthening out the apparatus the width of a finger at each addition ; 
upon this fresh strip another without plaster is placed, and so on suc- 
cessively until the whole bandage may be prepared. 

"Then we put the member upon the apparatus, which is moistened 
with a sponge from which the water has been squeezed out, and one 
applies first a strip without plaster and one with plaster on the same 
side, and immediately we adjust in the same manner the opposite ends. 
We continue thus until the whole apparatus is laid on. 

" In this manner there is always a strip without plaster between 
two strips with plaster, and vice versa." 
2<± 



370 GENERAL CONSIDERATION OF FRACTURES. 

In preparing the bivalved apparatus, Van de Loo describes two 
methods. In the first " we cut six plastered strips from two and 
half to three inches wide, and sufficiently long that they may extend 
from the superior part of the apparatus we propose to apply to three 
fingers' width below the soles of the feet, supposing, in the mean time, 
that we are operating upon the inferior member. 

" Then we arrange upon a cushion, protected with a towel, twenty- 
five or thirty plastered strips, also from two and a half to three inches 
wide, of which the longest should be about ten and the shortest six 
inches for a man's leg. Upon these plastered strips we place simple 
strips (without plaster); next we lay the fractured limb upon the 
apparatus, and we apply the simple strips ; then we take one of the 
six long strips which have been mentioned above, we moisten it well, 
and apply it upon the external side of the member from its superior 
part to below the sole of the foot; we place another of them in the same 
manner upon the internal side, leaving between the latter and the pre- 
ceding an interval of one or two widths of the finger ; this done, we 
moisten and apply the twenty -five or thirty strips with plaster upon 
them, which are arranged upon the towel ; we finish the bandage by 
moistening and applying successively the four remaining long plas- 
tered strips — that is to say, two upon the external side and two upon 
the internal — taking care to cover the first two." 

It is understood that in the case where the plastered strips which 
compose the apparatus of Scultetus should present a greater length 
than is necessary to apply them upon the margins of the valves, we 
should cut them as they are applied, that they may not encroach upon 
the space remaining free between the two halves of the bandage. 

To render this apparatus immovable, we fill up the space remaining 
free between the two valves with a little tow, and we apply three or 
four plastered strips crosswise, or better one or two strips of suitable 
width in the direction of the width of the interval, concealing it com- 
pletely. To establish the removability of the bandage, it will suffice to 
take away these strips. 

If the apparatus is intended to envelop the whole of the inferior 
extremity, twenty more of these strips are necessary, of which the 
longest should be seventeen and the shortest eleven inches, as well as 
six long strips, extending from the knee to the superior part of the 
apparatus. 

In the second method he directs that " we arrange two layers of 
strips without plaster, and superposed. We place upon the latter a 
piece of old blanket or flannel cut in proportion to the length of the 
leg, in a manner to embrace the posterior half or two-thirds of its 
circumference. This piece being previously impregnated with plaster 
upon its two faces, and upon that one which will be in contact with 
the limb, we arrange a layer of fine tow. The apparatus being thus 
prepared, we place the extremity upon it after having suitably 
moistened the plastered pieces, and we apply the whole by means of 
the superficial range of separate strips. 

•' The application of the first layer of strips being completed, we 
apply upon the anterior part of the leg a fresh layer of tow, or a 



: 

i 



GENERAL TREATMENT OF FRACTURES. 371 

compress without wrinkles, and above this another piece of blanket 
or flannel equally impregnated with plaster, and suitably moistened, 
which covers the anterior of the leg and encroaches, the width of two 
ringers, on each side, upon the posterior shell. The whole is then 
fastened by the range of strips which have remained unapplied. 

" Should we wish now to inspect the anterior part of the leg, we 
have only to detach the strips, and we can raise the piece of woollen 
cloth with the plaster on it, which protects this region, and afterwards 
reapply it, when we have examined the limb and finished the dress- 
ings required by the condition of the parts. 

" Supposing that the section should be made at the external side 
of the leg, for example, in front or behind the fibula, the hinge (or 
junction) will consequently be found upon the internal side, and extend 
the whole length of the bandage. All being arranged and the limb 
placed upon the apparatus, we commence by applying the layer of 
simple strips, as that is ordinarily practised. We adjust subsequently 
the first three plastered strips which embrace the whole of the lower 
part of the leg. With the three following strips we behave differ- 
ently in order to obtain at first a hinge, that is to say, a cloth connec- 
tion which serves as a pivot to the valves and permits them to be 
opened without ever compromising the form of the plastered shells. 
At the moment when we apply them we should take the precaution 
to cut them in their passage upon the hinge. An interval of a fraction 
of a line is permitted between the two ends produced by this section, 
and we continue the application of these upon the rest of the circum- 
ference of the member. The two strips which then follow are placed 
entire, that is to say, without being cut, in such a manner that they 
shall perform, at a later period, the office of hinges. In short we 
continue thus the alternate application of these cut strips, and two 
entire strips, in such a way that after the section we obtain a hinged 
apparatus perfectly 'movable-immovable,' applying itself exactly to 
the whole limb, and not liable to be thrown out of shape in conse- 
quence of the different dressings or examinations that the condition 
of the limb demands. 

" In order to render the plaster bandages perfectly ' movable,' it 
suffices to trace a groove in the plaster yet soft, immediately after the 
application of each apparatus, with the aid of the edge of a spatula, 
the back of a knife, or even with a small piece of coin. The groove 
thus traced suffices to constitute a joint which will permit the most 
extended movements to the valves that will be formed ulteriorly by 
the section of the bandage. For the inferior extremity we can, if we 
wish it, trace two lateral grooves in order to obtain two valves; 
whereas a single one will generally suffice for the superior extremity." 

In using plaster with water alone the dressing has to be conducted 
with inconvenient haste, that it may not harden before all the pieces 
of the bandage are in their intended positions. The " setting" of the 
plaster may be delayed by mixing with the water which is added to 
it various foreign materials. Those most commonly employed for 
this purpose are starch, dextrine, and glue. 

When starch is employed, its solution should be hot while the 



372 GENERAL CONSIDERATION OF FRACTURES. 

plaster is being mixed with it ; the proportion being equal quantities 
of the two materials, which must be incorporated little by little in an 
open dish. This mixture may be now used with the various forms 
of Van de Loo's bandages already described. 

A solution of dextrine has the same effect as starch; it is used cold. 
The proportion of these articles may be varied to suit the emergencies 
of each case : to obtain, for instance, the consolidation of a bandage 
in fifteen or twenty minutes, we may employ a pound of the plaster 
to about a pint of water containing one ounce of dextrine in solution, 
the plaster being added in small quantities at a time to the solution, 
which should be stirred constantly during the preparation of the 
mixture. 

I have been more in the habit of using glue in preparing plaster 
splints, and prefer it to any other article. The proportion will vary 
according as the consolidation is required to take place sooner or later. 
M. Eichet, who employs these materials in making his bandages, says 
that fifteen grains of glue to a quart of water will not sensibly retard 
the setting of the plaster, but that twenty -one grains will delay it 
twenty or twenty-five minutes, seventy-seven grains from three to five 
hours, and one hundred and fifty-four grains from ten to twelve hours. 
He directs the solution to be used at a temperature of 68° or 77° Fahr., 
and that the plaster be incorporated with it until a paste is made, 
which may be applied either with the hand or a spatula. M. Eichet 
prefers rollers made of tarlatan — a sort of a coarse gauze ; in the 
absence of this, coarse muslin may be used. He always protects 
the parts beneath with a dry roller, and places his plastered rollers 
over this, and if the bandage is required to have more strength, as 
when an entire extremity has to be inclosed, the paste may be smeared 
upon its outer side with the hand, and subsequently rendered smooth 
with a spatula. 

As a provisional dressing for fractures, and under circumstances 
where more efficient splints cannot be obtained, the apparatus of Scul- 
tetus will be found of real service. It consists of separate strips, 
straight splints, pads, and a splint- cloth. The strips may be from an 
inch and a half to two inches wide, and long enough to encircle the 
limb, and to overlap at each end three or four inches ; these are im- 
bricated from below upwards, each strip covering two-thirds of the 
width of its predecessor. The straight splints may be made of any 
material, such as wood, gutta-percha, pasteboard, or straw tied into 
little bundles by a cord wrapped spirally about them, but most com- 
monly the first is employed. The pads are usually prepared of oat- 
chaff* though any soft material may be used, as cotton, flannel, lint, 
etc. The splint-cloth is made of muslin or other stout cloth, and 
should be sufficiently long to go around the circumference of the limb 
three or four times. 

The apparatus is thus applied, for instance, in fracture of the thigh : 
Five strips of muslin, three for the thigh and two for the leg, are laid 
upon the mattress ; upon these the splint-cloth is spread, bearing on 
its upper surface a sufficient number of imbricated strips to reach from 
the foot to the groin ; the fracture is now to be reduced, and the limb 



FKACTURE OF THE SKULL. 373 

laid upon the strips, which are drawn over it from below upwards. 
Two lateral splints are now selected, the external one long enough to 
extend from the ilium to beyond the sole of the foot, and the internal 
one, from the perineum to the same point ; and an anterior splint to 
reach from the fold of the groin to the dorsum of the foot. The late- 
ral splints are rolled up in the splint -cloth from each of its ends 
towards the limb until but a narrow interval remains between them 
upon each side of the limb; two long pads are now introduced in 
these intervals between the limb and splints, while a third pad is 
placed beneath the long anterior splint, or the two short splints used 
by some surgeons. The splints arranged in this manner are to be held 
by assistants until the surgeon has secured them to the limb by the five 
strips of muslin above mentioned. The foot can be prevented from 
falling to either side by placing the middle portion of a strip of mus- 
lin upon its sole, crossing the ends upon its dorsum, and fastening them 
with pins to the lateral cushions. 

The apparatus may be prepared in a similar way for fractures of 
the leg and arm, though, in the upper extremities, instead of the strips 
the roller bandage is most always used to make the compression. 



CHAPTER II. 

SECTION I. 

FRACTURES OF THE BONES OF THE SKULL AND FACE. 

Fkacture of the Skull. — Fractures of the bones of the skull are 
the result of exterior violence, and often involve the brain and its 
membranes in inflammation and suppuration. These complications 
require the most active medical treatment, depletion, application of 
cold, purgation, etc. When fragments of bone are driven into the sub- 
stance of the brain, or the tables of the skull are beat in so as to press 
upon it, the case. demands certain surgical procedures, the application 
of the trephine, &c, which are more properly described in general works 
on surgery. 

The mastoid process of the occipital bone has been rarely broken 
off by direct violence, and displaced downwards by the contraction of 
the sterno-cleido-mastoid muscle. 

Treatment. — Incline the patient's head to the injured side, and retain 
it in the position either by the figure of 8 bandage of the head and 
axilla, or the double T of the forehead and chest. 

By the same sort of violence the external angular process of the 
frontal, bone may be broken and displaced inwards towards the eye, 
or backwards towards the temporal fossa; along with this injury there 
is always found fracture of the malar bone and zygomatic arch. 

In the treatment of such a case replace the fragment by pressure 



374 SPECIAL FEACTUEES. 

with the fingers, or by means of a lever, if there be a wound. There 
is no tendency to displacement by muscular action, so that a pledget 
of lint dipped in cold water and laid upon the part will be the only 
dressing required. 

If the injury is confined to the frontal bone, there will be no fur- 
ther trouble ; not so, however, if the eye is damaged, or, as is more 
often the case, the brain, by the same blow. The case is decidedly 
more serious, and requires a very guarded prognosis. These compli- 
cations are to be met by active antiphlogistic measures. 

Feactuee of the Nasal Bones and Caetilages. Causes. — 
The cause of fracture of the nasal bones is direct violence, such as is 
inflicted by blows with the fist, falls, and by gunshot wounds. The 
fracture may be simple or comminuted ; pass transversely through 
the lower third or middle of the bones, or vertically in a line with 
their length ; and sometimes the separation occurs at their junction 
with the nasal process of the superior maxillary. Earely a single 
nasal bone is broken. In these cases there will be more or less dis- 
placement, and sometimes fracture of the septum of the nose, though 
the latter occasionally happens even when the force is not sufficient 
to break the nasal bones ; the fracture takes place generally at the 
junction of the cartilage with the bony septum, or in the vertical 
nasal plate. The cartilaginous portion of the bridge of the nose may 
also be bent in or broken. 

The displacement occurs backward or laterally, according to the 
direction of the force brought against the nose. 

Symptoms. — There is almost immediately great swelling of the 
nose, with more or less bleeding from it ; the deformity is marked, 
and the fragments may be moved with the fingers, or with a thin 
metallic instrument, as probe or director, introduced into the nostrils. 
As the Schneiderian membrane is sometimes ruptured, the air is 
driven, during expiration, into the cellular tissue of the eyelids and 
the adjacent parts, producing emphysema. 

When the force causing the fracture is very violent, the brain and 
its membranes may be involved in inflammation and suppuration 
by the fracture running through the ethmoid, sphenoid, or frontal 
bones. In these complications, to the above symptoms there may be 
added those of concussion, and, in the worst cases, coma. 

Diagnosis. — Should the case be seen early, and a careful examina- 
tion had, there can be little difficulty encountered in making out the 
exact condition of the nasal bones; at a later period the diagnosis is 
exceedingly difficult, so that in a large number of cases of this injury, 
from the great swelling which ensues, the displacement of the frag- 
ments passes unrecognized either by the physician or by the patient. 
It is not until the tumefaction has disappeared that the marked de- 
formity resulting from even a trifling displacement of the fragments 
becomes apparent, and induces the patient to seek aid of the surgeon 
at a period when but little can be accomplished. 

Prognosis. — There is no danger to be feared in a case of simple 
fracture of the nasal bones, though when the ethmoid and frontal are 
involved in the fracture, as they sometimes are, and the brain 



FKACTURE OF THE NASAL BONES AND CAETILAGES. 375 

damaged, death will usually result from the injury, and hence the 
prognosis should always be guarded when these complications are 
suspected or are discovered to exist. 

The frequency of deformity following this injury should admonish 
us not to commit ourselves by any assurances as to the ultimate result 
of the case in this particular. 

Occasionally, also, catarrh and obstruction of the nostrils will be 
established and last for months ; in other cases, obliteration of the 
nasal duct, giving rise to fistula, epiphora, &c, has been noted ; and, 
rarely, an obstinate ulceration of the nasal mucous membrane and 
cartilages. 

Treatment. — In the treatment of this fracture our first object will be 
to make a thorough examination of the nose, and as this is exceedingly 
painful, the patient may be put under the influence of chloroform, if 
it is necessary, to accomplish this purpose. 

The reduction of the fragments may be effected with a thin steel- 
grooved director or probe, passed into the nares, and pressed against 
the bones from behind forwards, while, with the fingers placed upon 
the outside of the nose, counter-pressure is made. In this manner we 
must endeavor to restore the natural outlines of the organ. 

When the replacement has been effected, as there are no muscular 
fibres acting upon the fragments, they generally retain their position 
without any bandaging whatever, though it must not be forgotten 
that when the bones are broken into a number of fragments, sneezing 
or hawking may displace them, and the patient should therefore be 
cautioned to abstain from these actions as much as possible. 

Should the nose incline to either side, a narrow compress should be 
laid upon each side of the organ after it has been restored to its natu- 
ral position, and secured in place with the double T bandage of the 
nose, avoiding making any backward pressure. No plugging the 
nostrils with lint should be had recourse to, as it can do no good ; 
and this will be evident if anatomical structure of the upper and an- 
terior portion of the nares is considered. The space where pressure 
could be of any service is exceedingly narrow, and it is very question- 
able whether, with the swelling of the mucous membrane, it could be 
packed with lint. The same objections hold against the use of appa- 
ratus having levers connected with them, and intended to be intro- 
duced into the nostrils to support the bones. 

Consolidation takes place rapidly, and after the lapse of seven or 
eight days the fragments may become immovable. 

The only dressing required will be a light cloth, wrung out of cold 
water, laid over the nose. 

The excessive hemorrhage may require the nostrils to be tam- 
poned, an operation which will be described further on. 

If the septum of the nose is deviated to either side, we should 
endeavor to press it into its natural position with the point of some 
blunt instrument ; and if any tendency exists to a recurrence of the 
displacement, the nostrils should be equally padded with pellets of lint. 

Some authors recommend the use of a splint of the exact shape of 
the nose, and moulded to its outside. Dr. Hamilton, in a case in which 



376 SPECIAL FRACTURES. 

the bridge of the nose was depressed at the junction of the osseous 
with the cartilaginous portion, and the tip tilted forwards, restored it 
to its natural shape, one year after the accident, by loosening the 
depressed cartilage with a point of a bistoury, and, having passed a 
ligature through it, raised it to its proper level, where it was retained 
by tying the ligature over a gutta-percha splint accurately fitted to 
the nose ; the ligature was removed in two days, but the splint kept 
on two weeks. 

Fracture of the Superior Maxillary Bone. — Fracture of the 
superior maxillary bone may occur in its body or in its processes. 
As has already been stated, in the preceding article, its nasal process 
is sometimes broken at the same time that the nasal bones are crushed 
in. The alveolar process is sometimes damaged by violent efforts at 
extracting teeth, and Le Dran records a case in which a man had that 
portion of the alveolus containing the last four molar teeth broken off 
and lodged beneath the roof of the mouth, by a cart-wheel passing 
over his head ; the palate and gums remained entire. 

In other instances the violence is so great as to fracture the body of 
the bone and its palatal process ; and lastly, in gunshot wounds, both 
superior maxillaries may be destroyed. Kibes relates a remarkable 
case (JDiciionnaire des Sciences Medicates, torn, xix., art. Machoire), in 
which a soldier, at the siege of Alexandria, in Egypt (1801), was 
wounded by a shell, which carried away the right malar bone, both 
upper maxillaries, the greater portion of the lower jaw, the nasal 
bones, cartilages, and septum, the vomer, and a portion of the ethmoid 
bone. 

Causes. — From the firm manner in which the superior maxillaries 
are wedged in among the other bones of the face, it requires great 
and direct violence to break them ; though E-icherand and J. Cloquet 
each record a case in which the injury resulted from counter-stroke; 
in the first the chin and head were acted upon by two opposite forces, 
and in the other a violent blow was inflicted upon the chin from below 
upwards. These fractures are also accompanied with more or less 
contusion and laceration of the soft parts, and sometimes with cerebral 
disturbance. 

Symptoms. — The mobility of the fragments, when pressed with the 
fingers, the irregularity of the dental arch, if the fracture pass through 
it, and the apparent deformity, will generally declare the nature of the 
case. Extravasation of blood into the orbit will sometimes render 
the eyeball more prominent. 

Prognosis. — From the amount of injury necessary to cause a fracture 
of the upper jaw, particularly of its body, we should be exceedingly 
circumspect in delivering a prognosis, and especially when there is 
reason to suspect that either the brain or the ethmoid or sphenoid 
bones have been also implicated in the injury. An uncomplicated 
fracture will heal rapidly and safely, and in some cases it is astonish- 
ing how soon the consolidation occurs even when the fragments are 
loosely connected with soft parts. 

When the malar bone is driven in upon the antrum, some deformity 
will remain if it is not raised, and also a displacement of a portion of 



FRACTURE OF THE SUPERIOR MAXILLARY BOXE. 377 

the orbital process of the superior maxillary will result in the same 
manner and force the ball of the eye forwards. 

Should cerebral symptoms, as coma, delirium, &c, set in, we may 
infer that the fracture has extended to the bones at the base of the 
skull, which will render hopes of recovery very slender indeed. 

Treatment. — In a fracture of the nasal process of the superior maxil- 
lary, which, as already stated, occurs usually with a similar injury of 
the nasal bones, the treatment should be conducted in the same manner 
as for it ; that is, the reduction must be attempted with a slender steel 
instrument introduced into the nostrils, while pressure is made with 
the fingers upon the outside of the nose. 

When a portion of the alveolar process is broken, it should be 
restored to its natural position, and retained there by the simple 
expedient of closing the lower teeth upon the upper, and applying a 
sling bandage for the lower jaw. If this plan is not successful, any 
flexible and strong wire, such as iron or silver, may be used to tie the 
loosened teeth to the firm ones. To put the wire in place, pass its 
two ends between the teeth, and twist them together with the fingers, 
or, what is better, with a pair of long pointed pliers ; thread or silk 
may be also employed for the same purpose as the wire. 

In some cases a gutta-percha splint, moulded to the palatine vault 
and the teeth, will answer admirably in supporting the broken frag- 
ment. 

One of the superior maxillaries may be so loosened from its con- 
nections with its fellow and the other bones with which it articulates, 
that it becomes displaced to a considerable extent ; the palatine pro- 
cesses are separated from each other or override. In this case, when 
the reduction has been accomplished by pressure with the fingers in 
the mouth and a female catheter introduced in the nostril, the gutta- 
percha splint above mentioned may be applied, and the jaws held 
immovable by a sling bandage. A heavy blow struck upon the malar 
bone may break the anterior wall of the antrum and depress the 
cheek; this injury is commonly attended with a fracture of the alveo- 
lar process. In this case an effort should be made to raise the malar 
bone with the finger, introduced into the mouth between the gum and 
cheek, behind the zygomatic process. 

If there is a wound upon the face, a lever may be used with the same 
object; though rather than permit the bone to remain depressed a 
small incision should be made in front of the masseter through which 
the lever may be introduced beneath the malar bone. 

If the floor of the antrum is broken away, the point of the finger 
may possibly be put into that cavity and pressure brought to bear 
upon the posterior surface of the displaced bone. It has also been 
recommended to extract one of the molars so that a steel instrument 
might be thrust into the antrum ; but in extensive fracture of the 
upper maxillaries this plucking out of the teeth is not unattended 
with danger, and it would be much more preferable, in order to gain 
admission into the antrum, to perforate its anterior wall and use a 
curved lever. 

The removal of loosened fragments of the upper jaw should be 



378 SPECIAL FRACTURES. 

delayed as long as possible, for the reason that union does occur some- 
times under the most unfavorable circumstances. 

The fractures resulting from gunshot are to be treated upon the 
general principles already laid down, and although large portions of 
the upper jaw may be carried away and frightful deformity succeed, 
yet, after the lapse of some months, the recuperative efforts of nature 
do a great deal in remodelling the lacerated parts that they may be 
better able to perform their functions. When this is accomplished, 
the patient's condition may be made much more comfortable by the 
use of appropriate prosthetic apparatus. 

Fracture of the Malar Bone. Causes. — As in the case of the 
other bones of the face, fracture of the malar bone implies the appli- 
cation of great direct force to the part, as the kick of a horse, and is 
almost always accompanied with a fracture of the superior maxillary. 
A blow upon its orbital border may result in a fissure of this bone 
alone. In a few cases observed the bone, instead of being fractured, 
seems to have been simply displaced ; its orbital margin, being tilted 
forwards and pressing upon the eyeball, interferes with its movements. 

Diagnosis. — The depression of the cheek and mobility of the frag- 
ments when manipulated with the fingers will sufficiently establish 
the nature of the case. 

Prognosis. — Fracture of the malar bone without cerebral complica- 
tions will generally heal speedily, and, at the worst, only leave some 
deformity; while, on the other hand, disturbance on the part of the 
brain indicates associated damage to the neighboring bones, and 
renders the patient's recovery extremely doubtful. 

Treatment. — If there is a displacement of the fragments of the malar 
bone, they should be restored to their natural position in the manner 
already pointed out in the previous article. After the reduction is 
accomplished, water-dressings may be applied. Cerebral complica- 
tions must be met by appropriate treatment, according to their nature. 

Fracture of the Zygoma. — The zygomatic arch, formed by the 
zygomatic processes of the malar and temporal bones, although very 
slender, is yet rarely broken. 

Causes. — The causes are blows upon the malar bone, and violence 
acting directly upon the arch either from within or from without. 
Two cases are reported in which the injury resulted from force 
applied in the former manner, by a pointed instrument thrust into 
the mouth passing out at the temple and striking the arch. 

From the attachment of strong ligamentous and muscular fibres 
to the borders of the zygoma, it can well be understood that there can 
be but two directions in which displacement may occur, namely, in- 
wards and outwards, according as the force acts from within or from 
without. 

Symptoms. — The naturally curved outline of the zygoma can 
readily be felt with the fingers, so that when a case of fracture is seen 
early; any salient or re-entrant angle formed by the fragments of the 
broken bone in the temple can be readily felt; they may also be moved 
so as to develop crepitus. Should any sharp point of bone have 



FRACTURE OF THE INFERIOR MAXILLARY BONE. 379 

penetrated the masseter muscle, there will be difficulty in moving the 
lower jaw, and in some instances this is entirely impracticable. 

Prognosis. — A simple fracture of the zygoma is of little moment, 
and in all the recorded examples union has taken place promptly. 
Stiffness of the lower jaw will gradually pass away. 

If the violence has been very severe and the case is complicated 
with fracture of the facial bones, and cerebral disturbance, the danger 
will, of course, be in proportion to the extent of these complications. 

Treatment. — If the fragments of the broken zygoma form a salient 
angle in the temple, it may be depressed to the natural level by 
pressing upon it with the ball of the thumb. In an inward displace- 
ment, on the contrary, the depressed bone should be raised by pressing 
with the finger upon the inside of the cheek — a practicable procedure 
when the fracture is near the malar bone. If there is a wound, an 
elevator may be introduced beneath the zygoma and its elevation 
easily accomplished ; if the skin is intact, a small incision may be 
made, as was done in two of the recorded cases, to admit the point of 
the instrument. 

No apparatus is required after the reduction is effected, as the frag- 
ments will retain their position. 

Fracture of the Inferior Maxillary Bone. — Although the 
inferior maxillary bone forms so prominent a part of the lower portion 
of the face, yet it is not frequently fractured. This is due, in a great 
measure, to its mobility and arched form. 

Causes. — In a majority of instances the fracture results from direct 
violence, as the kick of a horse, or a blow with a club, or the fist ; it 
has also resulted from counter-stroke, as when a blow struck upon 
the side of the jaw breaks the neck of the condyle upon the opposite 
side ; the neck may also be fractured by a blow upon the chin. A 
third example of this injury from counter-stroke is where the angles 
of the inferior maxillary are pressed together when the fracture will 
occur at the symphysis. Portions of the alveolar process are some- 
times broken off by unskilful dental operations. Muscular action has 
also been recorded as an occasional cause. 

The bone may be fractured in its body, angles, ascending rami, necks 
of the condyles, or in the coronoid 
process (Fig. 304). Fi S; 304 - 

When the body of the bone suf- 
fers the line of fracture will, in a 
majority of cases, be found at or 
near the mental foramen. Boyer 
denies that it even occurs at the 
symphysis, yet accurate observers 
have met with such cases ; after the 
naval engagement at New Orleans 
one was admitted into the hospital 
under my charge. The fracture re- s P ecimen 6howin s *™ fo ™ s of fracture of the 
suited from a glancing shot which 

carried away the lower lip, and thus enabled me to get ocular demon- 
stration of the position of the injury. The patient was aged twenty 




380 SPECIAL FRACTURES. 

years ; the fissure was seated exactly vertical between the two middle 
incisors, which, though loose, were not dislodged from their alveoli. 
The young man made a speedy recovery, and I restored the lip by a 
plastic operation. 

As to the direction of the line of fracture in the body of the bone, 
it may be vertical, oblique, or horizontal ; generally it is backwards 
and inwards, so that the posterior fragment will ride over the anterior, 
the latter (if there is a fracture upon both sides) being drawn down- 
wards and a little backwards by the digastricus, genio-hyoid, and 
genio-hyo-glossus muscles. 

If the fracture is seated at the angles, the insertions of the masseter 
and internal pterygoid muscles will hold the fragments together so 
that there will be little displacement. 

One or both necks of the condyles may suffer at the time of the 
infliction of the injury; the external pterygoid muscle will draw the 
condyle upwards and inwards, while the masseter acting upon the 
angle of the jaw will displace the lower fragment forwards and up- 
wards, throwing the mouth open a little thereby; if the fracture is 
upon one side only, the chin will be turned a little to the sound side. 

When the line of fracture passes through the coronoid process the 
only displacement that occurs is by the temporal muscle pulling that 
process upwards. 

Symptoms. — Besides the displacements above described, the other 
symptoms of fracture of the lower jaw are mobility of the fragments, 
which can in nearly every case be developed by manipulation ; slight 
depression in front of the external meatus, if the injury is seated at 
the neck of the condyle, resulting from the upper fragment being 
drawn forwards and inwards ; crepitus, which may be felt when the 
jaw is moved, and pain at the point of injury. A fracture of the 
coronoid process can be ascertained by introducing the finger in the 
mouth and feeling the anterior edge of that process behind the last 
molar tooth when any existing mobility or crepitus would be perceived. 

The presence of any irregularity of the dental arch, loosening of 
the teeth, or laceration of the gums, will also furnish important infor- 
mation as regards the existence and seat of a fracture. 

Prognosis. — Fractures of the alveolar process usually result favora- 
bly ; the bone unites, and the teeth, if they have been loosened, become 
firmly fixed. The same satisfactory issue will usually be obtained in 
single fracture of the body, symphysis, and angles of the bone. When 
the fracture affects both sides of the jaw, or the necks of the condyles, 
some little deformity or irregularity of the dental arch will often 
result in spite of the best-conducted treatment. The prognosis in 
compound and comminuted fracture is still less favorable, implying 
the infliction of greater force upon the face, and rendering escape 
from some degree of deformity much less probable. Abscess some- 
times occurs in these cases, giving rise to tedious and troublesome 
exfoliations. 

In rare cases, paralysis of the muscles of the lower lip and convul- 
sions hive resulted from the injury. 

In making the prognosis it should also be remembered that a heavy 



FRACTURE OF THE INFERIOR MAXILLARY BOXE. 381 

blow struck upon the chin may produce serious injury to the bones 
at the base of the skull, hemorrhage from the auditory meatus, hard- 
ness of hearing, and buzzing in the ears. 

Delayed union has been observed in some cases ; according to 
Sanson union of the coracoid process with the ramus never takes 
place by bone. 

Treatment. — The reduction of a fracture of the body of the inferior 
maxilla, either single or double, is very easily accomplished by seizing 
the anterior fragment and raising it upwards and forwards until it is 
exactly level with the posterior one, which retains its natural position ; 
the adjustment is known to be perfect when the inferior border of the 
bone forms a regular and unbroken line. In fracture of one or both 
condyles with displacement of the fragments the reduction is not so 
easy ; for it will be necessary at the same time that the jaw is being 
drawn forward, to make pressure upon the condyle with the tip of the 
finger introduced into the mouth, so as to force it outwards, when it 
may be clamped between the lower fragment and the glenoid cavity 
by simply pressing the chin backwards and upwards. 

To maintain the fragments in their natural position various contriv- 
ances have been suggested and employed from an early date. One of 
the first was the ligature, which is to be applied around the necks of 
the teeth upon opposite sides of the line of fracture, and tied tightly. 
The materials of which the ligature is made may be any strong thread, 
or silver, gold, or platinum wire. 

Baudens, in a case of very oblique fracture complicated with a 
wound, bound the fragments together by means of a ligature passed 
around them in the following manner : he took a long needle flexible at 
its middle, and perforated with two eyes, armed with a ligature formed 
by twisting six or eight threads together ; the fracture having been 
reduced, while the fragments were steadied with the thumb and index 
finger of the left hand, he introduced the point of the needle at the 
lower margin of the inferior maxilla and carried it along its inner 
surface beneath the gum to the roots of the tooth, where the ligature 
was pulled into the mouth from the nearest eye ; the needle was now 
withdrawn to the lower edge of the jaw and passed between its outer 
side and the gum into the mouth again, where the ligature was re- 
moved from the second eye ; thus the jaw was inclosed in a loop, to be 
secured over the teeth or a splint moulded to them. Baudens stated 
that the case did well, and the ligature was removed on the twenty- 
fourth day. 

In two or three recorded cases the ends of a broken jaw have been 
perforated, and held together by a metallic suture. 

We have already described the sling and crossed bandages for the 
jaw, sometimes employed in the treatment of fracture of this bone. As 
an improvement upon these, Dr. J. E. Barton, of Philadelphia, recom- 
mended a bandage (Fig. 305), which he applied in the following manner : 
" A roller, an inch and a half wide, is placed just below the prominence 
of the os occipitis ; and he continues it obliquely over the centre of 
the parietal bone across the juncture of the coronal and sagittal su- 
tures, over the zygomatic arch, under the chin; and pursuing the same 



382 



SPECIAL FRACTUKES. 




Barton's bandage for a fractured 
jaw. 



Fig. 306. 



Fig. 305. direction on the opposite side until he ar- 

rives at the back of the head ; he then passes 
it obliquely around and parallel to the base 
of the lower jaw over the chin; and con- 
tinues the same course on the other side 
until it ends where he commenced, and re- 
peats." 

Prof. Gibson describes a bandage (Fig. 306) 
for the same purpose {Surgery, vol. i. 246). He 
says that after the jaw has been modelled into 
proper shape, and the mouth firmly closed, 
" then a cotton or linen compress of moderate 
thickness, reaching from the angle of the 
jaw nearly to the chin, is placed beneath 
and held by an assistant, while the surgeon 
takes a roller, four or five yards long, an inch and a half wide, and 
passes it by several successive turns under the jaw, up along the sides 
of the face and over the head ; now changing the course of the band- 
age, he causes it to pass off at a right angle from the perpendicular 

cast, and to encircle the temple, occiput, 
and forehead horizontally by several 
turns; finally, to render the whole more 
secure, several additional horizontal 
turns are made around the back of the 
neck, under the ear, along the base of 
the jaw, over the point of the chin. To 
prevent the roller from slipping or 
changing its position, a short piece may 
be secured by a pin to the horizontal 
turn, taking care to fix one or more 
pins at every point at which the roller 
has crossed." 

It should be borne in mind that, in 
using any of the above-described band- 
ages in fracture of the necks of the con- 
dyles, the horizontal turns around the 
chin and occiput have a tendency to throw the lower fragment 
upwards and backwards, a position just the reverse of that it ought 
to occupy. 

To secure greater firmness in the bandage, and to render it less 
liable to slip, the chin should be shaved, the hair cut short, and a 
muslin cap fitted to the head, to which the turns of the roller may be 
pinned. The same objects may also be obtained by smearing the 
bandage with solutions of dextrine, starch, plaster of Paris, or other 
consolidating material. 

In connection with these bandages it will be advantageous to 
employ a cap of softened pasteboard, sole-leather, or gutta-percha 
accurately moulded to the under and lateral parts of the lower jaw. 
Two broad strips of adhesive plaster, one encircling the top of the 




Gibson's bandage for a fractured jaw. 



FRACTURE OF THE INFERIOR MAXILLARY BONE 



383 



Fig. 307. 



Lead and under surface of the chin, and the other passing around the 
chin and occiput, will also make a good jaw-sling. 

Dr. Hamilton (A Practical Treatise on Fractures and Dislocations, 
p. 135) says that, having frequently noticed the tendency of the sling, 
as ordinarily constructed, and of Gibson's roller, to carry the anterior 
fragment backwards, he devised, several years since, an apparatus in- 
tended to obviate this objection. "It is composed (Fig. 307) of a firm 
leather strap, called maxillary, which, passing perpendicularly upwards 
from under the chin, is made to 
buckle upon the top of the head, at a 
point near the situation of the anterior 
fontanelle. This strap is supported 
by two counter straps, called, re- 
spectively, occipital and frontal ; 
made of strong linen webbing. One 
of these, the occipital, is attached to 
the posterior margin of the maxil- 
lary strap, about half an inch above 
the ear, and being carried around 
behind and under the occiput, it is 
finally buckled to the maxillary 
strap about half an inch above the 
ear; and being carried around be- 
hind and under the occiput, it is 
finally buckled to the maxillary 
strap upon the opposite side, and at 
a point exactly corresponding to its 
origin. The frontal stay simply 
antagonizes the occipital, and having 
its origin and termination at the anterior margins of the maxillary 
strap, it is buckled horizontally across the forehead, and just above 
the eyebrows." 

" The maxillary strap is narrow under the chin, to avoid pressure 
upon the front of the neck, but immediately becomes wider, so as to 
cover the sides of the inferior maxilla and face ; after which it gra- 
dually diminishes to accommodate the buckle upon the top of the 
head. The anterior margin of this band, at the point corresponding 
to the symphysis menti, and for about two inches on each side, is sup- 
plied with thread-holes, for the purpose of attaching a piece of linen, 
which, when the apparatus is in place, shall cross in front of the chin, 
and prevent the maxillary strap from sliding backwards against the 
front of the neck." 

We shall now consider a class of apparatus which contains con- 
trivances that have been recommended by many eminent and inge- 
nious surgeons. The principle upon which they are all based is nearly 
the same, namely, clamping the fragments of the jaw between two 
parallel forces acting in opposite directions. Desault seems to have 
carried the idea into practical effect in 1780. He employed a sub- 
mental splint of sheet-iron, or some other material, to which were 
attached sliding-hooks, armed with pieces of cork or plates of lead, to 




Hamilton's apparatus for a fractured jaw. 



384 SPECIAL FRACTUEES. 

catch upon the crowns of the teeth. Since that time surgeons have 
made a great many improvements upon his clumsy apparatus, and 
achieved much success in the treatment of fractured jaw. 

Baron Boyer {Traite des Maladies Chirurgicales, vol. iii. p. 131) 
recommends that when the fracture is oblique and double, in order to 
prevent deformity of the jaw, a cork splint grooved in the form of a 
gutter upon both its faces, to accommodate the teeth, should be placed 
between the dental arches, and the jaws held together by a sling band- 



Dr. Mutter, of Philadelphia, substituted for the cork splint a clamp 
of silver, as more cleanly, and not as liable to be broken as the cork is; 
others, still, have made the splint of ivory and certain kinds of wood. 

Gutta-percha is, perhaps, one of the best materials of which to make 
inter-dental splints ; it adapts itself evenly to the jaws and teeth, does 
not decay, and with proper care does not become fetid by the secre- 
tions of the mouth. It may be used in the following manner ; take 
two pieces of the gutta-percha of the proper size, soften them in water, 
and place one of them upon each side of the jaws, which being pressed 
together imbed the gums and teeth into the material. After a few 
minutes the gutta-percha hardens and forms an exact mould of the 
parts, when the two lateral splints may be removed, and properly 
trimmed to remove rough points, or irregular edges ; they are then 
pat in place again, and the jaws held together by the four- tailed 
bandage of the chin. 

Malgaigne {Traite des Fractures, torn. i. p. 395) describes an apparatus 
consisting of a narrow and thin lamina of flexible steel, capable of 
adapting itself to all the irregularities of the posterior dental arch ; 
from its two extremities, and two intervening points, equally distant 
from them, four little metallic pins arise to the level of the crowns of 
the teeth, which they cross, and are then bent so as to run parallel with 
their anterior surfaces ; the extremities of the pins are furnished with 
four little thumb-screws to clamp the plate against the back of the 
teeth. To prevent the screws damaging the enamel a plate of lead is 
interposed between them. 

In another class of contrivances a submental splint is introduced to 
which the dental splint is attached. 

One of the first instruments of this kind is that of Eutenick, in- 
vented in 1799. It has since been modified by Bush, Hartig, Lons- 
dale, Houzelot, and Jousset (see Atlas of F. J. Behrend, PI. 7, Figs. 18, 
19, 20, 22). 

Several years ago I contrived an apparatus (Fig. 308) which was used 
successfully in twelve cases of fractured jaw, more than half of which 
were compound, and resulted from gunshot. I made a model of the 
lower jaw with softened pasteboard, and then spread this out on block 
tin, which was marked, cut into shape, and modelled so as to fit the 
inferior maxilla exactly, with two arms extending up in front of the 
ears. The horizontal part was so rounded as to fit the lower edge of 
the bone for its whole extent, and projected upwards towards the alve- 
olar process about half an inch, and backwards beneath the chin an 
inch and a quarter — this edge being circular, and fitting the neck 



FRACTURE OF THE INFERIOR MAXILLARY BONE. 385 

above the hyoid bone. The splint is then covered with buckskin, and 
padded here and there, as pressure is necessary, at this or that point. 
Three straps (1, 2, 3) are attached to the apex of the arms of the splint 

Fig. 308. Fig. 309. 





The author's apparatus for fractured jaw. 

and buckle over the head — all being secured in the median line by a 
strap (4). Another strap (5) passes through a bracket, soldered under 
the body of the apparatus, and buckles over the head. 

To the anterior part of the apparatus a slat is soldered, through 
which passes a perpendicular bar of stiff and flattened wire bent oppo- 
site the mouth at a right angle, and projecting into it. To the point 
of the wire a dental splint is attached, which is made of tin, and fitting 
the teeth clasps them on either side, leaving an interval between its 
lateral limbs, as seen in Fig. 309. This, the dental splint, is movable 
along with the perpendicular bar, which slides through the chin-slat, 
and can be secured by the thumb-screw. 

I now make both the dental and submental splints of gutta-percha, 
instead of tin. The advantages of this apparatus are that the sub- 
dental splint forms an exact model of the natural configuration of the 
jaw, in which the fragments of the broken bone repose in a natural 
position, and shielded from all lateral pressure from bandages, which 
is often a cause of displacement ; by means of the straps the jaw may 
be pressed in any desired direction, and held immovable until consoli- 
dation occurs; and lastly, the dental splint prevents the fragments 
overriding, and separates the jaws sufficiently far to enable the patient 
to take fluid aliments. 

Dr. Beans, a dentist of Atlanta, Ga., has treated over forty cases of 
fractured jaw, with great success, with an interdental splint of vulca- 
25 



386 



SPECIAL FKACTUKES. 




Maxillary articulator. 1, 1. Upper and lower 
plates. 2,2. Adjustable rods. 3,3. Adjustable 
hinge. 



nite, which is prepared in the fol- 
lowing manner : Take impressions 
of the teeth of the upper and 
lower jaws — those of the latter in 
each fragment separately — in wax, 
in the ordinary manner of dentists. 
Upon these make plaster of Pa- 
ris casts, which are to be placed 
in the position that the jaws would 
naturally occupy closed, and held 
in a metallic frame called a " max- 
illary articulator" (Fig. 310). 

The casts are now separated 
from three to five lines, and a wax 
splint built up between them, leaving an interval in front through 
which aliment may be introduced. 

Prepared in this way, the model jaws are removed from the " articu- 
lator," and a cast made of them in plaster of Paris, from which the 
wax is now to be removed, and the space left by it filled with India- 
rubber softened with heat ; the mould 
is then placed in a dentist's "flask," 
and heat applied until the rubber is 
thoroughly vulcanized. The splint 
is now finished, and is to be removed 
from the flask. 

The splint is applied to the teeth, 
which it fits very accurately, and the 
jaws are closed by a submental splint 
formed of a transverse piece of wood, 
provided with a cup at its centre to 
receive the chin, and supported by 
the straps in the way seen in Fig. 311. 
For the first three or four weeks 
of treatment, a patient with a frac- 
tured jaw should take nothing but 
fluid aliments, and after the removal 
of the apparatus it will be advisable 
for him to use soft food for a few 
days, in order not to jeopardize the safety of the osseous union by 
mastication. The mouth should be frequently cleansed with tincture 
of myrrh or a mixture of Labarraque's solution in water. 



Fig. 311. 




Bean's apparatus for fractured jaw. 



SECTION II. 

FRACTURES OF THE BONES OF THE TRUNK. 

Fracture of the Hyoid Bone. — The hyoid bone, from its mo- 
bility, and protected situation beneath the chin, is rarely ever fractured. 

Causes. — The causes of the injury are blows upon the front of the 
neck in falling against some hard object; and pressure with the fingers 
in grasping the throat, or from a ligature. A case is reported where 



FRACTURE OF THE LARYNGEAL CARTILAGES. 387 

the accident resulted from muscular action, the head having been 
violently thrown backwards. It has been most frequently observed 
in aged persons. The fracture may affect the body or one or both 
cornua of the hyoid. 

Symptoms. — At the time of the infliction of the injury the patient 
experiences a sensation as if something had been crushed at the upper 
part of the neck, in which part and the jaw severe pain is felt, 
aggravated by the least motion of the head or mouth ; articulation 
and deglutition are often impossible, or performed with the greatest 
difficulty; the tongue cannot be protruded from the mouth; and there 
will be tumefaction and contusion, often accompanied with ecchymosis 
of the front of the throat. 

If there is any displacement of the fragments, it will occur inwards, 
producing some irregularity in the contour of the hvoid; crepitus may 
generally be developed, either by manipulating with the fingers or by 
efforts of deglutition. Other symptoms have also been recorded as 
sometimes accompanying this injury, such as hemorrhage from the 
pharynx, in consequence of the wounding of its mucous membrane by 
a spicula of bone; suffocation, cough, and expectoration. 

Prognosis. — Simple fracture of the hyoid will commonly unite in 
from six to eight weeks ; should the case, however, become compli- 
cated with severe inflammation, abscess, or necrosis of the bone, from 
the violence of the injury or the laceration of the neighboring soft 
parts, the life of the patient will be seriously compromised. 

Treatment. — If there is displacement of the fragments, reduction 
should be at once attempted by pressing them outwards with the 
point of the finger introduced into the pharynx. There is no tendency 
of the fragments to slip away from each other after they have been 
brought into their normal relations, so that position of the head alone 
suffices to maintain the reduction. This should be one of moderate 
extension, to establish a uniform traction of the muscles inserted in 
the hyoid bone above and below. Excessive inflammation must be 
controlled by local depletion and saturnine and anodyne applications. 

Should the patient not be able to swallow, aliment may be intro- 
duced into the stomach with a long flexible tube ; but it will always 
be better to deny the patient everything for the first three or four 
days except what is absolutely required. 

Abscess in the neck should be opened at once, and the first oppor- 
tunity sought to remove any portion of the bone that may have become 
necrosed. Should suffocation threaten, tracheotomy will, of course, be 
demanded. 

Fracture of the Laryngeal Cartilages. — The thyroid and cri- 
coid cartilages may be fractured either separately or together. As to the 
character of the fracture, it may be simple, comminuted, or compound. 

Causes. — The causes of the injury are direct violence inflicted upon 
the part, as grasping the throat forcibly between the fingers, falls upon 
some hard projecting ridge, kicks of a horse, and gunshot. During 
the late war I saw three cases of fractured thyroid cartilage from the 
last- mentioned cause, two of whom died, and autopsy revealed the 
nature of the injury; the third recovered. 



388 SPECIAL FRACTURES. 



Symptoms. — The only certain symptoms of this injury are crepitu 
mobility of the fragments, and deformity of the larynx ; other phe- 
nomena are, however, in most cases present — difficult respiration, 
whispering voice, or the voice may be entirely lost, deglutition painful 
or impossible, cough, hemorrhage from the larynx, and emphysema of 
the neck. 

Prognosis. — Fracture of the laryngeal cartilages, even when simple, 
is a serious matter; and if the violence inflicting it is severe, or if 
there should be displacement of the fragments, or complications of 
any sort, such as severe inflammation, &c, the patient almost always 
loses his life. 

Treatment. — The object of the practitioner should be to combat local 
inflammation, by leeching and other suitable antiphlogistics. When 
the respiration begins to be labored, tracheotomy or laryngotomy 
must be had recourse to at once ; it will be fatal to the welfare of the 
patient to delay the operation too long. If the larynx is comminuted, 
and the fragments displaced, the safest plan will be to perform laryn- 
gotomy, and restore them to their natural situation. 

Fracture of the Vertebrae. — From the firm interlocking of the 
vertebrae, which are bound together by strong ligaments and covered 
by powerful muscles, great violence is required to be inflicted in 
order to fracture them. The fracture may affect the body, laminae, 
spinous or transverse processes. Its direction in the body of the 
vertebrae may be vertical or oblique, and in the latter case it usually 
runs downwards and forwards, causing the upper fragment to slip in 
a corresponding direction. 

In the recorded cases of this injury affecting the laminae, the line of 
fracture has occurred nearly vertical, and upon both sides. 

The transverse processes are rarely ever broken, and then always 
by a gunshot or penetrating wound which inflicts grave injury upon 
the surrounding tissues and organs. 

Causes. — The causes are blows upon the line of the spine, falling 
upon the back against some hard and projecting object, alighting 
upon the head, or buttocks, or even upon the feet after being precipi- 
tated from a height ; and gunshot wounds. 

Symptoms. — The symptoms of fractured vertebrae will vary accord- 
ing to the extent of the injury, and its locality. A moderate blow, 
especially an oblique one, upon the back, may simply knock off the 
spinous processes, or even fracture the laminae without entailing any- 
thing beyond a moderate amount of concussion of the cord which 
will reveal itself by a paralysis of the lower extremities, disappearing 
after the lapse of some weeks or months ; there will also be added 
some derangement of the secretory action of the kidneys. In other 
cases not even these disturbances will be present. 

In a fracture of the bodies of the lumbar vertebrae there will be 
paralysis, commonly both of sensation and motion, of the legs ; and 
paralysis of the bladder and rectum, so that the patient cannot pass 
the urine, or relieve his bowels ; or those excretions pass away from 
him involuntarily. With these symptoms others are often associated, 
as crepitus, mobility of the fragments, and posterior angular projec- 



e- 



FRACTURE OF THE VERTEBRA. 389 

tion of the spinous process of the fractured vertebras, which will mate- 
rially assist in removing any doubt in the mind of the surgeon as to 
the nature of the injury. 

When the fracture is higher up — in the dorsal region — to the above 
enumerated symptoms must be added derangements of the stomach, 
nausea, vomiting, &c, and tympanitic distension of the abdomen. 
And, as it would be expected, when it is yet higher, but beneath the 
third cervical, the functions of the heart and lungs will also be dis- 
ordered ; there will be palpitation, difficulty in respiration^ and con- 
gestion of the face from obstruction to the capillary circulation. The 
muscles of the chest and those of the upper extremities will also be 
paralyzed. 

A fracture implicating the first three cervical vertebrae, which are 
above the phrenic nerve, and attended with displacement of the frag- 
ments and compression of the cord, must necessarily result in immedi- 
ate death from asphyxia. 

In all these cases the urine becomes alkaline, producing chronic 
inflammation of the bladder, which adds greatly to the sufferings of 
the patient. 

Should the person survive the injury some time, inflammation arises 
in the cord and its membranes, and terminates in effusion and suppu- 
ration. 

From the lowered vitality of the tissues pressure upon the sacral 
and gluteal regions causes sloughing sores ; in some cases, the destruc- 
tion is so rapid that the parts almost seem to melt away. 

Diagnosis. — The nature and extent of a fracture of the spine cannot 
always be made out, for excepting the deformity, crepitus and mo- 
bility of the fragments, all the other symptoms may be, to a greater 
or less extent, the result of concussion, strains of the cervical muscles 
and ligaments, with damage to the cord, and dislocation of the ver- 
tebras, and therefore, in certain cases, we are left altogether in the. dark 
until an autopsy reveals the character of the injury. 

Prognosis. — The prognosis will vary with the seat of injury. As 
we have already stated a fracture of the first three vertebras accom- 
panied with compression of the cord must be followed by death upon 
the spot ; in those cases where the injury is seated in the lower cervical 
region the fatal issue is commonly delayed from three to seven days; 
in the dorsal, from one to four weeks, and in the lumbar region, from 
four to six weeks, or the patient may sometimes, in the latter case, 
survive the accident two or three years. 

Death in these cases results from asphyxia, or from gradual exhaus- 
tion and nervous irritation often attended with profuse diarrhoea. 

Fractures of the processes of the vertebras, especially when un- 
associated with compression, are much more favorable than those of 
their bodies. 

There are cases of these injuries recorded where patients have 
recovered to a greater or less extent, but they never regain the full 
enjoyment of all their bodily functions. 

Treatment. — From the obscurity in the diagnosis of fracture of the 
vertebras the greatest care and judgment are required in determining the 



390 SPECIAL FRACTURES. 

proper manipulative procedures to be employed. In case the spinous 
processes are broken and displaced, their position may be rectified, 
and the reduction maintained by laying two thick compresses upon 
either side of the spine and securing them with a broad body-bandage. 

Fracture of the laminas with depression has given rise to a good 
deal of discussion as to the propriety of operative interference to 
correct the displacement of the fragments; certain cases have been 
successfully treated by raising the depressed arch, but experience and 
reasoning do not sustain the utility of the operation as a general mode 
of practice. It will, in general, be better to place the patient in the 
easiest and most comfortable position upon a firm mattress or a water- 
bed, and to pursue an expectant plan of treatment ; avoiding every- 
thing that would cause an unnecessary amount of motion of his body. 
Purgatives in the early part of the treatment should be avoided, and 
the urine must be removed with a catheter, as often as its accumula- 
tion renders it necessary. 

Caution should be observed in making those changes in the position 
of the patient's body required for the purpose of changing his linen 
or bedclothes; and in no case should he be placed upon his face 
when the fracture is located in the cervical region and the thoracic 
muscles are paralyzed, for then the respiration is performed only by 
the diaphragm and the abdominal muscles, and to place the patient 
upon his belly under these circumstances would arrest the action of 
these muscles and thereby cause asphyxia. 

Those portions of the back coming in contact with the bed must be 
protected as much as possible with air cushions, and should bed-sores 
form in spite of these precautions, they should be kept scrupulously 
cleansed, and covered with a dressing prepared by spreading lead plaster 
upon buckskin ; after the sloughs have separated, stimulating applica- 
tions of basilicon, storax, Labarraque's solution, &c, will be useful. 

The occurrence of local inflammation at the seat of injury should 
be met by appropriate antiphlogistic remedies, leeching, and water- 
dressings. 

At a later period, when the acute symptoms have disappeared, in- 
frictions of the extremities with camphorated and stimulating liniments, 
containing the tincture of cantharides, and strychnia internally in 
doses of the one-sixteenth to the one-twelfth of a grain three times a 
day, will be serviceable in aiding the restoration of nervous power. 

Fracture of the Sternum. — Fracture of the sternum is a rare 
form of injury in consequence of the elasticity of the thoracic walls 
and the spongy structure of this bone. 

The fracture may be transverse, oblique, or longitudinal, the former 
being the most common ; or, again, it may be simple, comminuted, or 
compound. It may be located at any point of the bone, but is most com- 
monly encountered in the neighborhood of the junction of the manu- 
brium with the middle piece. With advancing years the bone becomes 
more brittle, and it is late in life that the fracture is relatively most fre- 
quent. 

Causes. — In a majority of cases the fracture results from direct in- 
jury, as the passage of a heavy wheel over the chest, or the fall of a 



FRACTURE OF THE RIBS. 391 

large piece of wood across it. Cases are reported in which it resulted 
from muscular action alone. 

Symptoms. — The symptoms of this fracture will consist of those 
arising from the injury to the bone itself, and those from injury to the 
thoracic viscera. Among the former will be noticed displacement of 
the fragments, the lower one commonly slipping in front of the upper 
— a position due, according to Sanson, to the greater length of the ribs 
attached to the former portion ; crepitus, which is more easily made out 
when the ear is applied to the chest, and pain at the seat of fracture. 
The symptoms dependent upon damage to the viscera of the chest are, 
palpitation, difficulty in breathing, cough, expectoration of blood, 
emphysema, and inflammation of the lungs and pleura. A case is re- 
ported in which the violence was so great as to drive a fragment of 
the bone into the heart and to cause death outright. 

Prognosis. — As this injury always implies that great force has been 
inflicted upon the chest, especially when it occurs in young persons, 
the prognosis must in a majority of cases be unfavorable, and more 
particularly when the fracture results from direct violence and is com- 
plicated with disturbances of the thoracic organs. The occasional 
results of this injury are abscess of the anterior mediastinum, and 
caries or necrosis of the sternum. 

Treatment. — When there is an overlapping of the fragments it has 
been recommended to effect the reduction by bending the body back- 
wards over a pillow placed between the shoulders. Some surgeons 
direct the depressed bone to be raised by a lever, the point of which 
is placed beneath it, or to sink a screw into its substance and use this 
as a handle. 

When the reduction has been effected a compress is to be laid over 
the point of injury and confined by a body bandage ; the patient must 
be placed upon his back with the thighs drawn up and supported with 
pillows, while the head and shoulders are thrown somewhat posteriorly. 

If an abscess should form in the mediastinum it should be opened 
as soon as it points at the margin of the sternum. Necrosis and caries 
of the bone are to be treated in the manner taught in general works 
on surgery. 

Fracture of the Kibs. — Fracture of the ribs, though not so un- 
common as that of the sternum, is yet comparatively infrequent. The 
cause of this is the elasticity of the walls of the chest, which of course 
is influenced to a greater or less extent by the age of the subject. The 
upper ribs are so effectually protected by the scapula behind and the 
clavicle in front, with their attached muscles, that their fracture is ex- 
tremely rare. The floating ribs enjoy the same immunity by virtue 
of their mobility. 

The fourth, fifth, sixth, and seventh ribs are most frequently frac- 
tured. Its line is generally transverse, though it often is oblique, and 
may even be somewhat longitudinal. Comminuted and compound 
fractures are met with in some cases, and in the latter instance 
result from the fragments of the bone penetrating either the lungs or 
skin. 

Causes. — The causes are the same as those of fracture of the ster- 



392 SPECIAL FRACTURES. 

imm — great force being applied to the chest producing the fracture 
directly or by counter-stroke ; in the latter case, as when the chest is 
violently compressed between the bumpers of railroad cars, and the 
ribs break at some intermediate place between the points compressed. 
Malgaigne has recorded eight cases of fracture from muscular action. 

Symptoms. — If there is displacement of the fragments of the broken 
ribs, which can only occur to any extent inwards or outwards, angular 
deformity will result — the angle being in the former case re-entrant or 
depressed, and in the latter salient ; crepitus can be generally detected 
by directing the patient to breathe deeply, or what is better, cough, 
though in certain cases it may be masked by the swelling of the parts 
or emphysema ; preternatural mobility of the fragment may also be 
made evident by pressure with the fingers. Besides these positive 
diagnostic signs there will almost always be present other symptoms 
indicating injury to the thoracic viscera, as cough, haemoptysis, em- 
physema of the chest, severe pain over the seat of injury, or diffused 
over the chest and aggravated by coughing or sneezing; later, pleu- 
ritis or pneumonia may arise. 

Prognosis. — We can always expect a favorable issue in a case 
of simple fracture of the ribs, particularly of the middle ones, when 
there is no displacement or only an outward projection of the frag- 
ments, in from twenty to thirty days. 

If the fragments are driven inwards upon the viscera so as to wound 
them to any extent, the prognosis becomes very serious, for a large 
proportion of such cases will terminate fatally in a longer or shorter 
time from the inflammatory complications that will be set up. These 
cases are particularly serious in persons with a tendency to tubercu- 
losis, as this disease *is extremely apt to be developed. 

. Treatment. — The reduction of the fracture, if the fragments project 
exteriorly, is accomplished by pressing with the finger upon the angle 
which they form ; if they are depressed upon the lungs and produce 
threatening symptoms, their elevation is indicated either with the fin- 
gers or an elevator introduced through the wound ; should there be no 
wound, under circumstances of danger I think we should be justified 
in making one. Cases requiring such treatment must be exceedingly 
rare in civil practice; in gunshot wound of the chest I have been com- 
pelled, in a number of cases, to remove from the lungs spiculae of bone 
an inch or more long. The only bandage required in these cases is one 
encircling the chest to retain the ribs immovable. A compress may or 
may not be placed beneath it over the seat of injury, according as there 
is or is not a tendency to displacement of the fragments externally. 

Should the displacement be inwards a compress must be placed 
upon the anterior and posterior extremities of the ribs, and confined 
by a circular bandage. The bandage I am in the habit of using in 
these cases is composed of a number of adhesive strips two inches wide 
and long enough to encircle the chest once and a half, applied circularly 
and imbricated. After the bandage has been applied the patient should 
be placed in the most comfortable posture, and subsequent inflamma- 
tory complications combated by appropriate antiphlogistic remedies. 

Fracture of the Costal Cartilages. — Fracture of the costal 



FRACTURE OF THE SCAPULA. 



393 



cartilages arises from the same causes as fracture of the ribs. The 
eighth cartilage is most frequently affected, and in all cases the line 
of fracture is smooth and transverse. The usual displacement observed 
is the riding of the internal fragment over the outer one, if the seat of 
fracture is near the sternum, and the reverse when it is more remote. 
Treatment. — The same general line of treatment must be observed in 
dealing with a case of fractured costal cartilage as has been pointed out 
at page 392, for the ribs. Malgaigne recommends, for the purpose of 
preventing 'displacement of the fragments, the application of a truss 
to the chest, one of the pads of which should press upon the seat of 
the fracture. 



SECTION lit 

FRACTURES OF THE BONES OF THE UPPER EXTREMITIES. 

Fracture of the Scapula. — From the resiliency of the thoracic 
walls, the strength, mobility, and the thickness of the muscular cover- 
ings of the scapula, fracture of this bone is rather uncommon. It 
may affect the body, the neck, the coracoid or acromion process or 
the inferior angle of the bone. 

1. Fracture of the acromion process (Fig. 312) is the most frequent 
variety met with in the scapula. It may be 
located either at, behind, or before the acromio- 
clavicular articulation : in the first two instances 
the shoulder losing the support of the clavicle 
will fall forwards and downwards; and in the 
latter the tip of the acromion will simply be 
depressed upon the head of the humerus. The 
direction of the fracture is generally transverse. 

Cause. — Blows or falls upon the shoulder or 
elbow. 

Symptoms. — The shoulder being no longer 
supported by the clavicle approximates to the 
median line, and is depressed ; the head of the 
humerus falls into the axilla as far as the cap- 
sular ligament will allow ; the arm hangs 
helplessly by the patient's side, who usually 
endeavors to take the weight of the limb off the fractured bone by 
supporting the elbow with the hand of the uninjured arm; if the hand 
be placed upon the shoulder while the elbow is forced upwards so as 
to bring the fragments in contact, crepitus will be perceptible ; and 
lastly, in tracing the spine of the scapula, that portion of it between the 
fracture and clavicle will be found depressed. 

Diagnosis. — Fracture of the acromion may be confounded with 
dislocation of the humerus into the axilla and fracture of the clavicle 
outside of the coracoid process. It is distinguished from the first 
by the circumstances that in fracture the deformity may be made to 
disappear by raising the elbow, and it will immediately be reproduced 
as soon as the support is removed, and the acromion will not present 
that prominent appearance it does in dislocation. Extra-coracoid 




Fracture of the acromion process. 



394 SPECIAL FRACTURES. 

fracture of the clavicle will present little displacement of the frag- 
ments, no alteration in the rotundity of the shoulder, and the arm can 
be easily moved by the patient; these circumstances will suffice to 
distinguish this injury from fracture of the acromion process. 

Prognosis. — The union between the fragments is usually liga- 
mentous; and when it occurs by bone, it is generally with some 
obliquity of the outer fragment, which does not impair the free move- 
ments of the arm. 

Treatment. — When the tip of the acromion is broken off, the best 
position for the arm is at right angles to the body, so that the deltoid 
muscle may be relaxed, and the fragment tilted upwards. As this 
position requires the patient to keep in a recumbent posture, he will 
perhaps decline the treatment ; in that case, the only thing the sur- 
geon can do is to support the arm in a sling. In those instances in 
which the shoulder loses the support of the clavicle, and falls down- 
wards and forwards, the treatment is the same as that for fractured 
clavicle, except that the axillary cushion may be of equal thickness, 
as advised by Desault. 

2. Fracture of the coracoid process (Fig. 313) is an extremely rare 
form of injury, and very difficult of diagnosis, from the situation of the 

bone, and the great amount of violence 
Fig- 313. necessary to be inflicted to cause it, pro- 

ducing, at the same time, complications, 
such as fractures of the clavicle, sca- 
pula, and humerus, and contusions of 
the soft parts which effectually shield 
it from detection. The seat of the 
fracture may be in any part of the 
process, or even extend into the glenoid 
cavity. 

There can scarcely be much dis- 
placement of the fragments by the con- 
Fracture of the coracoid process. traction of the short head of the biceps, 

coraco-brachialis, and pectoralis minor 
inserted into the process, unless, at the same time, there should be a 
rupture of the ligaments connecting it above with the acromion pro- 
cess and clavicle. In this case, it will take place downwards. 

Symptoms. — The patient will be unable to adduct the arm, and, if 
there is not much swelling, the process may be grasped in the fingers, 
and moved so as to develop crepitus. 

Treatment. — The indications of treatment are to render the scapula 
immovable by a body bandage crossing the injured shoulder, and to 
carry the elbow well forwards upon the chest, to relax those muscles 
inserted into the coracoid, and then to support the elbow and forearm 
in a sling. 

3. Fracture of the neck of the scapula (Fig. 314) is also a very uncom- 
mon injury, and results from great violence inflicted upon the shoulder. 
It is sometimes attended with damage to the axillary plexus of nerves 
producing paralysis, and injury to the brachial artery. The line of frac- 
ture passes from the semilunar notch downwards to the anterior border 




FRACTURE OF THE SCAPULA 



395 




Fracture of the neck of the scapula. 



of the scapula, and therefore separates Fi s- 314 - 

both the glenoid fossa and the cora- 

coid process from the body of the 

bone. The weight of the limb carries 

the anterior fragment downwards and 

forwards. 

Symptoms. — There will be a de- 
pression observed beneath the acro- 
mion, giving the shoulder a depressed 
appearance, and the head of the hu- 
merus will be felt in the axilla ; the 
limb, upon measurement, will be found 
longer than its fellow ; crepitus is per- 
ceived when the surgeon places the 
tip of the index, finger of the left hand 
upon the coracoid process, the rest of 
the fingers of that hand embracing the 
shoulder, while, with the right hand, 

he seizes the arm below, and moves it in various directions. The 
coracoid itself will be found at a greater distance from the clavicle, 
and obeying the movements of the humerus rather than, as it should, 
those of the scapula. 

Diagnosis. — From dislocation of the head of the humerus into the 
axilla this injury may be distinguished by observing that in the 
latter the depression below the acro- 
mion is not so deep, and it may be 
effaced, and the rotundity of the shoul- 
der restored by raising the elbow ; the 
deformity being immediately restored 
the moment the support is withdrawn. 

In fracture of the neck of the hu- 
merus the arm is shortened, and the 
rounded outline of the shoulder will 
not be disturbed. 

Treatment. — The indications of treat- 
ment in this case are simply to render 
the scapula immovable, and to carry 
the anterior fragment upwards and 
outwards. They can be best fulfilled 
in the following manner : Place a pad 
in the axilla, with its base upwards ; 
press the elbow towards the chest and 
a little to its front ; surround the arm 
and chest with a body bandage ; and 
lastly, support the elbow and forearm in 
a sling. Such an apparatus is seen in 
Fig. 315; the sling is not shown. 

4. Fracture of the body of the scapula is produced by great vio- 
lence inflicted upon the chest, and is usually accompanied with con- 
siderable injury to the soft parts surrounding the bone, producing 



Fig. 315. 




Apparatus for fracture of the neck of the 
scapula. 



396 



SPECIAL FRACTURES. 



Fig. 316. 




The ordinary situation of fracture of 
the body of the scapula. 



such an amount of swelling as to obscure the nature of the injury. 
The resulting inflammation is often so severe as to eventuate in necrosis 
of the bone, and impairment of the functions of the upper extremity 

which either happens at once or succeeds 
to the injury. 

The fracture may be incomplete, simple, 
or comminuted, and the line of its direc- 
tion vertical, transverse, or oblique. Any 
portion of the body may suffer, the spine 
or the portions above or below this ; but 
it is most commonly seated below the 
spine, running obliquely from the anterior 
to the posterior border, as seen in Fig. 316. 
There will not be much, if any, dis- 
placement of the fragments in a vertical 
fracture; but in a transverse one they 
will be separated, the levator of the angle 
of the scapula, and the rhomboid muscles 
drawing the superior fragment upwards; 
while the serratns magnus, latissimus dorsi 
and teres major draw the inferior one 
downwards. 
Symptoms. — If the case is seen early, by carefully examining the 
borders and angles of the scapula any fissure or separation of the 
bone may be detected ; to facilitate the examination, the arm should 
be moved in different directions, so as to give greater prominence to 
the different portions of the scapula. In these movements, crepitus 
may often be perceived by reposing the hand over the bone. The 
functions of the arm will be more or less impaired, from the combined 
injury to the bone and to the soft parts surrounding it. 

Treatment. — The only bandage required in this case is to sling the 
elbow and forearm so as to raise the shoulder, that the muscles inserted 
into the upper fragment of the scapula may be relaxed, and the por- 
tions of bone thus brought into contact. 

5. Fracture of the inferior angle of the scapula arises from the same 
causes as produce the same injury of the body of the bone. The 
nature of the displacement will depend upon the extent of the muscu- 
lar insertions into the angle spared ; the serratus magnus alone will 
carry the fragment forwards, while it, in conjunction with the latissi- 
mus dorsi and the teres major, will displace it forwards and upwards, 
or forwards and downwards. 

Symptoms. — There will be mobility of the separated angle, and 
crepitus can always be produced by moving the fragments in opposite 
directions ; these symptoms, with a knowledge of the history of the 
case, will enable the surgeon to make a correct diagnosis. 

Treatment. — It must always be borne in mind that in all transverse 
fractures of the scapula great difficulty will be encountered in main- 
taining the fragments in contact ; and even when it is effected, they 
will usually unite awry. It is, however, consoling to know that this 
result cannot impair the usefulness of the arm. 



FEACTUKE OF THE CLAVICLE. 397 

In applying the retentive bandage, authors have differed consider- 
ably as to the best position in which to place the arm. Some direct 
the elbow to be carried in front of the chest, some to the rear, while 
others prefer to retain it in a line parallel with the vertical axis of the 
body. The axillary pad has been considered necessary by some, and 
has been condemned as useless by others. 

In the midst of these conflicting opinions, it would appear the most 
rational plan to reduce the fracture, and place a thick compress along 
the anterior border of the scapula, then to surround the chest with a 
broad bandage passing from the injured to the sound side; the scapula 
being rendered immovable, the arm should be put in that position 
which most completely relaxes the muscles inserted into the fractured 
angle, and prevents displacement. It may be that this requires the 
elbow to be moved in front of the chest, towards the posterior aspect, 
or retained in a vertical direction. When the object has been obtained, 
the limb is to be secured by a circular bandage embracing the arm 
and chest, while the forearm and elbow are supported in a sling. 

Desault advises an axillary pad, with its apex looking upwards, so 
that the elbow may be kept away from the side. This plan may be 
adopted or rejected, according as it secures the object in view or not. 

Fractuee of the Clavicle. — From the peculiar curved shape, 
slenderness, exposed position, and functions of the clavicle, it is fre- 
quently broken. According to the statistics of Malgaigne, of 2358 
cases of fracture of different bones, 228 were of the clavicle, and of 
these three-fourths were met with in the male. It is encountered in 
all ages, from infancy to old age. 

The fracture may be unilateral or bilateral, complete or incomplete, 
simple or comminuted or compound; the most common variety being 
the simple, while the others are comparatively rare. The line of frac- 
ture is almost invariably more or less oblique, and often distinctly 
serrated. Its seat is generally in the middle third of the bone, to the 
inner side of the coraco-clavicular ligament, a circumstance which is 
explained by the fact that at this point the clavicle is more slender 
than elsewhere, and it also begins here to change the direction of its 
curve, so that an extraneous force must necessarily act upon this spot 
more energetically than upon any 
other. _ _ Fi §' 317 - 

Causes. — The most common cause 
of fractured clavicle is by counter- 
stroke from falls upon the point of 
the shoulder; direct violence also 
produces the same result. In a few 
recorded examples, muscular action 
was the cause. 

The line of fracture of the middle 
third, in a majority of cases, is oblique 
from above downwards and inwards, 
as seen in Fig. 317 ; so that the shoul- 
der, losing the support of the clavicle, 

.,: , P , rr , . , t* ■% Oblique fracture near the middle of tl 

will be drawn by the weight of the ciaTicie. 




398 SPECIAL FEACTUEES. 

upper extremity downwards, while the contraction of the subclavius 
and pectoralis major and minor will give it a direction forwards and 
inwards. The sternal fragment, stayed above by the sterno-cleido- 
mastoid muscle, and below by the costo-clavicular ligament, maintains 
nearly its natural position, or is simply elevated a little; on the other 
hand, the acromial fragment, following the movements of the shoulder, 
will overlap the former upon its under surface for half an inch or 
more. When the line of fracture is in the reverse direction, as it 
sometimes is, the inner extremity of the outer fragment will be, in a 
measure, sustained. 

Displacement of the pieces in fracture seated between the insertion 
of the sterno-cleido-mastoid and the attachments of the costo-clavicular 
ligament, or between the coraco-clavicular ligaments, cannot take place 
to any extent, while a fracture outside of the latter ligaments will be 
attended with a posterior displacement of the external fragment, which 
will unite with anterior angular deformity in spite of the best treatment. 

Symptoms. — Besides the apparent deformity caused by the displace- 
ment of the fragments above described, if the fingers are conducted 
along the clavicle from within outwards, they will suddenly encounter 
a depression at the seat of injury, and they will then pass on to the 
acromion upon a lower plane formed by the outer fragment; crepitus 
will be perceived when the pieces of bone are seized between the 
fingers and rubbed upon one another, or better brought into contact 
by drawing the shoulder outwards ; the arm hangs by the body, and 
is rotated inwards ; the patient inclines his head to the damaged side, 
and instinctively endeavors to support the shoulder by holding the 
forearm in the hand of the sound limb; there will be severe pain 
about the fractured bone, which is aggravated by the slightest motions 
of the arm. The functions of the upper extremity will generally be 
more or less destroyed, though it is not uncommon to meet with pa- 
tients who can lift the hand of the injured side over the head. 

Contusions should be sought upon the point of the shoulder or 
elbow where the injury has resulted from counter-stroke, or over the 
clavicle when from direct injury. 

In fractures of the inner and outer thirds of the clavicle deformity 
will not be so apparent, and therefore these cases require the closest 
scrutiny to arrive at a correct diagnosis. 

The same remark likewise applies to incomplete fracture, which 
generally occurs in young subjects, and is characterized by a node-like 
swelling at the seat of injury, obscure crepitus, and impairment of the 
functions of the limb, and when the point of injury is pressed upon 
with the tip of the finger severe pain is caused. 

Prognosis. — In simple fracture of the clavicle by contre-coup the 
patient, if he be an adult, will generally do well, and consolidation 
will occur in about five weeks; in a child, union occurs in eighteen or 
twenty days. Fractures from direct blows upon the clavicle are not 
so favorable, nor are those which are comminuted, compound, or com- 
plicated. 

The subclavian nerves and vessels may be so injured as to cause 
paralysis or aneurism, and even death. A case of compound commi- 



FRACTURE OF THE CLAVICLE. 



399 



nuted fracture from gunshot came under my care, in which the sub- 
clavian artery was laid bare and could be seen plainly pulsating at 
the bottom of the wound ; the patient recovered after a tedious illness 
and necrosis of more than half of the clavicle. 

Treatment. — The reduction of the fracture is very easily accom- 
plished by simply raising the elbow and pressing the shoulder out- 
wards, or by approximating the shoulders posteriorly, the knee having 
been previously placed between the scapulas. As a general rule, it 
may be stated that though the reduction is so easy, yet in those cases 
of complete oblique fracture of the adult it will be impossible to 
retain it by any apparatus whatever, and union will therefore occur 
with some degree of overlapping or deformity. 

The indications of treatment are plain, the shoulder must be carried 
upwards, outwards, and backwards. The difficulties encountered in 
the treatment are not that these indications cannot be fulfilled tem- 
porarily with suitable bandages, but that, sooner or later, the apparatus, 
of any description whatever, will become deranged or loosened while 
the patient is permitted to move around as he ordinarily is during the 
treatment, and thus the object in view — immobility of the clavicle — 
will almost certainly be defeated. 

To facilitate the comprehension of the various contrivances which 
have been employed in the treatment of this injury, we shall divide 
them into three classes, according to their mode of action : — 

1. Apparatus which fulfil one indication only, namely, maintaining 
the shoulder backwards. — Under this heading are to be placed the 



Fig. 318. 



Fig. 319. 




Figure of 8 bandage for fractured clavicle. 



Brasdor's apparatus for fractured clavicle. 



posterior figure of 8 bandage of the shoulders and its numerous 
modifications. 



400 SPECIAL FRACTURES. 

The figure of 8 bandage may be applied as seen in Fig. 318, which 
shows also the combination with it of an axillary pad and a circular 
bandage for the purpose of throwing the shoulder outwards. Without 
these modifications the figure of 8 bandage was employed by Albucasis 
and the Arabian school of surgeons. In France it found supporters 
in Guy de Chauliac, Lanfranc, and A. Pare; J. L. Petit, following the 
example of Hippocrates, enjoined an inter-scapulary compress. 

Brasdor employed a corselet, consisting of a dorsal plate with lateral 
straps for the shoulders, and steadied by a circular belt around the 
waist, as seen in Fig. 319. 

In Germany, Heister brought forward his dorsal iron cross with 
lateral straps, and subsequently Bruninghausen employed transverse 
leather straps connected with shoulder-pieces. Hubenthal, Brefield, 
Koppenstater, Eicheiner, and Evers invented apparatus based upon 
the same principle (see Atlas of J. F. Behrend, Plate 13). 

In this country there are still some apparatus employed which act 
in the same maimer as the figure of 8 bandage ; of these one invented 

by Dr. Kecherly is seen in Fig. 
Fig. 320. 320. " The upper figure exhib- 

its a front view, and the lower 



r ' * . i 

I I 

i p — r .. P , -„S | I 



a back view of the splint, a, a, 
are two bandages with buckles 
attached to one end of each ; 
bb, bb, are four mortised holes 
for the passage of the two band- 
© © ages; a, a, c, a portion of the 

Ij-u ft d lb s P^ nt padded, to prevent its 



bruising the patient ; d, d, two 
loops of leather, tacked on the 

Kecherly's apparatus for fractured clavicle. back of the Splint, for the pas- 

sage of the bandages, where the 
mortised holes are too far apart for the breadth of the patient from 
shoulder to shoulder." In applying this apparatus "the end of the 
splint corresponding to the uninjured side is to be pressed close to the 
back of the shoulder, and retained so by drawing the bandage tight, 
and retaining it by means of a buckle. Previous to fixing the band- 
age, it should be passed through two loops on a small pad, which 
is to be placed in the axilla. This pad is used for the purpose of 
preventing cutting of the bandage. After passing the other bandage 
through two loops, on a large cuneiform pad, which is placed in the 
axilla of the injured side, it is drawn sufficiently tight and secured by 
the buckle. The last thing to be done is to place the handkerchief, 
doubled in a triangular form, in such a manner over the arm, the front 
and back parts of the thorax, as that it shall draw and confine the 
arm of the injured side close to the body, give it support, and prevent 
its falling down." 

2. Apparatus which fulfil two of the indications, namely, sustaining 
the shoulder upwards and backwards. — Although we find these two 
indications carried in the spica, scarf; and sling bandages of Hippo- 
crates, Celsus, Paulus JEgineta, and Galen, yet in modern times 



FRACTURE OF THE CLAVICLE. 



401 



surgeons have not had the same confidence in this class as in the 
former. The spica of Glaucius, described by Galen, is stated by Yel- 
peau to be the original of Desault's bandage. L. Richter and Gluge 
have employed the descending spica of the arm. 

M. Mayor recommends a bandage prepared with a square piece of 
muslin folded in a triangle, the base of which was placed between the 
arm and chest, the lateral angles extending around the latter, while the 
depending angle was carried beneath the elbow, brought up over the 
forearm and chest, and its two parts separated, one angle passing over 
each shoulder and fastening to the bandage behind. He believed that 
in a majority of cases this bandage would be efficient, but should the 
deformity persist, he directs an axillary pad to be used. 

M. Velpeau has described a bandage which he speaks of in the 
following manner: "I have contrived a bandage, by means of a 
simple roller, which is adapted both to sterno-clavicular luxations, for 
which I had at first designed it, and also to acromio-clavicular luxa- 
tions, fractures of the clavicle, acromion, and scapula, and even to 
fracture of the neck of the humerus. For this purpose we procure 
a bandage of eight to ten yards in length. The head of this bandage 
is first applied under the armpit of the sound side, or behind, as with 
the cataphrast; it is then passed diagonally upon the back and 
shoulder to the clavicle, 

upon the side affected. The Fi g- 321 * 

hand of the patient is then 
placed upon the acromion 
of the sound shoulder, as if 
embracing this last. The 
elbow thus raised is brought 
in front of the point of the 
sternum, and the affected 
shoulder is pushed upward, 
backward, and outward, by 
the action of the humerus, 
which taking its point (Tap- 
put on the side of the chest, 
acts like a lever of the first 
kind, or by a swing-like mo- 
tion. While an assistant 
keeps the parts in place, the 
surgeon brings down the 
bandage upon the anterior 
surface of the arm, then 
outside and under the el- 
bow, to bring it upward and 
forward under the sound 
armpit. He repeats this 
three or four times, in order 
to have that number of 
diagonal turns, which obliquely traverse the wounded clavicle, the 
upper part of the chest, and the middle portion of the arm. In place 
26 




Velpeau's apparatus for fractured' clavicle. 



402 SPECIAL FRACTURES. 

of bringing back the bandage to the affected shoulder, it is afterwards 
passed horizontally upon the posterior surface of the thorax, and 
brought back upon the external surface of the arm, elbow, or forearm, 
in the form of circulars, which are repeated until the hand which is 
on the sound shoulder and the stump of the affected one alone remain 
uncovered. We finish by one or two more diagonals, and by a similar 
number of horizontal circulars. 

" Another bandage, well saturated with dextrine, and applied exactly 
in the same manner over the first, makes a kind of immovable sac, in 
which the elbow rests without effort, and without having the power to 
move itself either backwards, outwards, or forwards. I have already 
employed it a great number of times, and it has appeared to me so 
simple, and of such easy application, that I do not hesitate to offer it 
as preferable to all those that have been hitherto proposed." 

The arm may be very conveniently and efficiently supported in the 
position recommended by Yelpeau by means of long strips of adhesive 
plaster, about an inch and a half or two inches wide, passing obliquely 
around the arm and sound shoulder, and circularly around the chest. 
If it is deemed necessary an axillary pad may be employed, though 
generally it will not be required. Wattman's bandage is similar to this. 

A dextrine bandage is also recommended by Chassaignac {Gazette 
des Hdpitaux, 1853). He bends the arm of the injured side at an 
angle of 90°, covers the forearm and lower half of the arm with a 
layer of carded cotton, and over this applies a roller soaked in a solu- 
tion of dextrine. He now reduces the fracture, places a compress 
over the lateral and posterior surface of the neck of the sound side 
and another between the chest and forearm ; with a second dextrined 
roller he secures the arm to the thorax by oblique turns running 
beneath the elbow and across the cervical compress. 

Kicherand and B. Bell employed simple slings to support the arm. 

3. Apparatus which fulfil the three indications of supporting the 
shoulder backivards, upwards, and outwards. — The first decided pro- 
gress made in the treatment of fractured clavicle was after the intro- 
duction of the bandage of Desault, which fulfilled the indications 
above mentioned better than any contrivance that had been used up 
to that time. It is executed with three rollers each three inches wide 
and eight yards long ; a wedge-shaped cushion three inches wide at 
its base and seven inches long, gradually tapering towards the apex. 
In applying it the patient is seated upon a stool, or stands erect, while 
an assistant holds the injured arm at right angles with the body ; the 
surgeon places the wedge in the axilla with its base upwards and has 
it supported close to the body until he has placed the initial ex- 
tremity of the first roller upon it and made three circular turns around 
the chest and the wedge to sustain the latter in its position, then the 
roller is conducted in front of the thorax over the sound shoulder 
under the corresponding axilla to appear in front again, thence around 
to the back, over the sound shoulder down in front of the axilla, 
beneath this to the back, when the roller is exhausted by circular 
turns around the chest, each turn overlapping two-thirds of the width 
of its predecessor. 



FRACTURE OF THE CLAVICLE. 403 

The arm is now brought against the wedge and the forearm flexed 
at right angles, carrying the elbow a little in front of the chest when 
the second roller is to be applied in the following manner : place its 
initial extremity under the axilla of the sound side, conduct its head 
obliquely across the chest, to the acromion around the upper part of 
the arm and chest, to the axilla again, its point of departure ; thus 
continue with the circular turns until the arm and upper half of 
the forearm are covered in. This roller answers the important indica- 
tion of forcing the shoulder outwards, the humerus being used as a 
lever of the first kind acting upon the axillary wedge as a fulcrum ; 
hence it is important that the lower turns acting upon the elbow 
should be drawn tighter than those above. 

The third roller serves the purpose of keeping the shoulder upwards 
and backwards, and is applied by placing its initial extremity under 
the axilla of the sound side, then conduct the cylinder over the broken 
clavicle, upon which a compress must be placed, down the posterior 
surface of the arm under the elbow, and over the forearm to the point 
of departure; thence across the back obliquely over the injured 
shoulder, down the front of the arm and under the elbow, to pass ob- 
liquely across the chest to the axilla of the sound side. In this man- 
ner two triangles are formed, one in front and the other upon the pos- 
terior surface of the chest ; continue to lay on these turns until the 
roller is completed. The forearm is supported in a sling. 

This bandage becomes loosened and requires to be tightened every 
five or six days, or even more often according to circumstances. 

It keeps the patient under a good deal of restraint, and the turns of 
the roller often compress the thorax painfully, particularly in women. 
Cloquet states that at the hospital of St. Louis the third roller was 
omitted, and a sling for the elbow and forearm substituted. He fur- 
ther says that the treatment was usually successful, and the modified 
bandage could easily be borne by women. 

Dupuytren, Cruveilhier, and Elamant also employed a bandage 
formed of two rollers. 

In order to remedy the defects in the apparatus of Desault, Boyer 
invented a bandage which bears his name. It consists of an axillary 
pad made of bran, placed in the axilla and supported by two ribbons 
fastened to its superior angles and tied over the sound shoulder ; of a 
belt of quilted muslin five inches wide, to surround the chest, and 
fastened by three buckles and a corresponding number of straps; of 
an armlet of the same material some four or five inches wide, lacing 
upon the arm ; to the armlet four straps are attached, two in front and 
two behind, and which pass through corresponding buckles upon the 
thoracic belt anteriorly and posteriorly. These straps are the charac- 
teristic feature of Boyer's bandage ; with them the power is applied to 
throw the shoulder outward. The forearm is supported in a sling. 

Bottcher omits the armlet, and incloses the lower part of the arm 
with the thoracic belt. 

Delpech's apparatus is formed of, 1st, a body bandage of stout mus- 
lin extending from the axilla to a point about two inches above the 



404 SPECIAL FKACTUKES. 

crest of the ilium, gored at the sides, and fastening in front by six 
buckles and a corresponding number of straps ; to prevent the band- 
age slipping down it is supported by shoulder-straps, while four thin 
strips of whalebone, sewed in the muslin, keep it from working into 
ridges ; two loops made of muslin are fastened to a point of the band- 
age about two inches from its upper margin. 2d. A wedge-shaped 
pad, with a width at its base the diameter of the arm, and long enough 
to reach from the axilla to the elbow ; the pad is sewed to the body 
bandage so that its base exactly occupies the axilla. He directs the 
pad to be made of quilted horsehair and covered first with a layer of 
quilted wool and then with a second layer of carded cotton also 
quilted; the whole to be nicely covered with muslin. 3d. A four- 
tailed sling of sheepskin covered with chamois and well padded with 
cotton at the centre to receive the elbow. Bach of the heads of the 
sling are split into two short straps, the anterior being pierced with 
holes and the posterior provided with four buckles. In using the 
apparatus the body bandage is to be neatly applied, with the axillary 
pad in its proper position, the elbow is brought to the side and engaged 
in the body of the sling, the posterior straps are carried obliquely 
across the back, and engaged in the loop near the upper border of the 
bandage, the two inferior buckles being conducted over the shoulder, 
and the two superior under the axilla ; the anterior straps are also 
engaged in their loop, and the two lower tongues engaged in the 
buckles coming over the shoulder, and the upper ones into those ap- 
pearing beneath the axilla. 

From the descriptions of the above bandages it will be seen, that in 
France in the treatment of fractured clavicle the forearm was always 
placed in front of the body, and supported either with a sling or with 
the turns of a roller. 

M. Guillou {JjAbeille Medicate, October, 1847) reported to the 
Academy of Science of Paris an innovation upon this plan ; he stated 
that, for some years, he had been in the habit of treating fracture 
of the clavicle by placing the forearm across the back of the chest, 
instead of in front, as was the general custom, and that his success 
justified him in preferring this method to all others. 

This apparatus consisted of — 1st. A sling made of a folded handker- 
chief of an appropriate length; 2d, a cravat; 3d, of a body bandage; 
4th, a square cushion of linen, thicker in its middle than along its 
margins ; 5th, a pad having a ribbon a foot and a half long attached 
to each side of its base. In employing the bandage place the wedge- 
shaped pad in the axilla and sustain it in that position by tying the 
ribbon attached to it over the opposite shoulder. The body of the 
cravat is put around the upper part of the injured arm and its tails 
carried behind the shoulder ; the arm is now brought to the side while 
the forearm is thrown across the back and supported in the sling de- 
pending from the neck; the square compress is laid between the 
scapulae and sustained in this position by the tails of the cravat, which 
are now made to cross it, and to tie around the sound shoulder; lastly, 
the body bandage is made to surround the chest and arm, and is to 
be securely pinned. 






FRACTURE OF THE CLAVICLE 



405 



Fig. 322. 



The actions of the different parts of the bandage are obvious ; the 
sling raises the shoulder ; the body bandage presses it outward by 
acting upon the humerus as a lever; while the cravat pulls the 
shoulder outward, the square cushion over which it passes giving it 
greater leverage. 

This apparatus of Guillou, as may readily be conceived, is at first 
very irksome to the patient from the unusual position in which the 
arm is placed ; but in a few days he will generally become reconciled 
to it. More serious objections, however, to the bandage are, that it 
interferes with a comfortable indulgence in recumbency, and rotates 
the arm inwards, so as to throw the axillary vessels and nerves more 
directly against the pad. 

Mr. Lonsdale {Treatise on Fractures, pp. 212, 213) describes a very 
simple bandage, seen in Fig. 322. It consists of a wedge-shaped pad, 
secured in the axilla with a roller, upon which the arm is to be laid. 
The elbow is drawn to the front of the 
chest, and confined by a few turns of a 
roller around them, while the forearm 
and elbow are supported in a short 
sling, as shown in the figure. 

In America, perhaps, no apparatus 
has been so popular, or so generally 
employed as that invented by Dr. Fox 
in 1828 (Fig. 323). It is extremely sim- 
ple, and the materials of which it is pre- 
pared may be obtained almost every- 
where ; and lastly, it answers as well in 
the treatment of fractured clavicle as 
any of the bandages yet suggested. As 
to its asserted efficacy in accomplishing 

CUreS Without deformity in all Cases of Lonsdale's apparatus for fractured clavicle. 

this injury, there is certainly a mis- 
take, arising, perhaps, from want of accurate observation. Its supe- 
riority over other sling bandages that have been in use in Europe for 
years, and descriptions of some of which we have already given, con- 
sists in the simplicity of the materials used in making it, and the 
ease with which it can be prepared. 

The bandage is composed of, 1st, an axillary wedged-shaped pad, 
about half the length of the humerus, and with a thickness at the 
base of two and a half to three inches; just enough, in fact, to keep 
the arm free from, and parallel with the side, and having attached to 
its base two long tapes. 2d. A padded ring, an inch or two thick, 
and sufficiently large to embrace the shoulder. 3d. A sling, made of 
muslin, and extending from the middle of the humerus to the wrist, 
having attached to its superior border one tape, and two tapes to its 
inferior angles. 4th. A sling for the hand. 

In applying the apparatus, slip the padded ring over the sound 
shoulder ; then place the pad in the axilla of the injured side, and 
support it in position by tying the two tapes attached to its base, 
to the padded ring, before and behind. Now bring the arm, bent 




406 



SPECIAL FRACTUKES. 




Fox's apparatus for fractured clavicle. 



Fig. 323. at right angles, against the pad ; 

place the elbow in the sling ; then 
carry the upper tapes behind the 
chest, and the other two in front, 
and tie them to the padded ring ; 
the hand is supported in the 
sling. 

In Fox's apparatus the pad 
serves the purpose of a fulcrum, 
upon which the humerus is made 
to move as a lever of the first 
kind, by applying power to the 
lower part of the arm with the 
aid of the tapes. The head of the 
huuierus may thus be thrown out- 
wards and backwards as far as 
may be required to effect the re- 
duction of the fracture, by simply 
varying the tension of the tapes. 
Dr. Hamilton has suggested a desirable modification of Fox's appa- 
ratus, to obviate pressure upon the axillary vessels and nerves. It 
consists in allowing the arm to hang vertically beside the chest, and 
in employing a pad that will just fill the axilla when the elbow is in 
contact with the body. He says that "in consequence of having 
placed the elbow further back than is recommended by Dr. Fox, it 
will be necessary, also, to vary in some way the suspensory tapes; 
those coming from the humeral portion of the arm-tray must pass in 
equal numbers and in opposite directions, before and behind the body, 
towards the stuffed collar; and each set of front and back tapes, 

attached to the humeral portion of the tray, 
must be in pairs, for the convenience of 
tying. I find it necessary, also, to secure 
the arm to the body by two or three turns 
of a roller, applied always lightly and with 
great care, so that its pressure shall be in 
no degree painful or uncomfortable." The 
proper application of this apparatus is seen 
in Fig. 324. 

Another ingenious form of the sling band- 
age is the one contrived by Dr. E. J. Levis, 
of Philadelphia (Fig. 325). As described by 
him, it consists of a short, firm pad in the 
axilla, by which the shoulder is held from 
the side, and over which, as a fulcrum, the 
elbow is drawn to the side. To the front 
and back of the axillary pad are fastened 
straps, which pass directly upwards, and 
are buckled to a wide main supporting 
band, which passes from the shoulder 

Hamilton's apparatus for fractured ^, A c ,-t -i i i 

clavicle. across the upper part of the back, and over 



Fig. 324. 




FRACTURE OF THE CLAVICLE. 



407 



the shoulder of the sound side, and terminates on the front of the 
chest. By this means the shoulder is supported, and the pad im- 
movably held high in the axilla, where its pressure can be more 
conveniently borne than when its widest part compresses the brachial 
nerves and vessels lower down; besides, a better leverage is thus 
given to the arm over the pad. To the front end of the wide 
supporting band is suspended a sling, by which the elbow is sup- 
ported. On the back of the sling, at a short distance above the point 



Fig. 325. 



Fie. 32d. 





Levis's apparatus for fractured clavicle. 



Le vis's apparatus applied. 



of the elbow, a strap is attached, which passes obliquely across the 
back, and, coming in front, is buckled to the main supporting band. 
The action of this strap is to draw the elbow to the side, at the same 
time supporting it ; and its opposite attachment in front prevents the 
tendency of the wide band to ride upward and press uncomfortably 
on the superficial vessels of the neck. 

By this combination, united so as to form one continuous piece, 
requiring no extra bandage over it, the shoulder is firmly held in the 
proper direction without any risk of yielding or slipping of the ap- 
paratus, and so secure that the most restless patient cannot dis- 
arrange it. 

In adjusting the apparatus, the arm is passed through the opening 
above the pad, the wide band thrown across the opposite shoulder, the 
elbow placed in the sling, and the long strap attached to the back of 
the sling brousrht round in front. 

In removing it from the patient, it is only requisite to loosen the 
back strap which draws in the elbow, by unbuckling it at its front at- 
tachment. The other straps need never be removed from the buckles. 

The extra buckle, which will be noticed at the front end of the wide 



408 SPECIAL FRACTURES. 

supporting band, comes into use when the apparatus is reversed for 
the opposite shoulder. 

The apparatus may be made of any strong material, as webbing, 
drilling, or soft leather. The width of the wide band should be from 
two to four inches. The straps which press upon the surface were 
slightly padded in the apparatus as the inventor has used it, but this 
may not always be essential, and temporary pads might be placed if 
the pressure should become anywhere uncomfortable. Thus con- 
structed, it can be very speedily prepared at an emergency, and but- 
tons and buttonholes might even take the place of buckles. 

Probably the true principle of treatment in dealing with fracture 
of the clavicle, especially in its middle third, is to act upon the lower 
posterior angle of the scapula of the injured side, and to some extent 
upon its inner and posterior margin, by pressing it upwards, back- 
wards, and outwards, so as to make a lever of it with the posterior 
surface of the thorax as a fulcrum, and thus by restoring the scapula 
to its proper position at the same time to restore the shoulder and with 
it reduce the fragments to their proper apposition. The weight of the 
upper extremity, which is the chief cause of the falling or drooping of 
the shoulder, should be removed by a sling upon the flexed forearm 
or by a pillow in case the patient is confined to bed; and the pressure 
on the scapula may be effected by confining the patient in the supine 
position with a firm, hard pillow or compress broad and long enough 
to make decided pressure on the whole back of the chest, or with a 
compress so applied and maintained as to press especially upon the 
lower and inner posterior margin of the scapula of the injured side. 
The old instrument of Brasdor will answer this purpose with slight 
modifications and was probably intended to do so by its author ; but 
a firmer and more efficient apparatus has been proposed by Dr. Ed- 
ward Hartshorne, of this city. Dr. Hartshorne advocated this princi- 
ple of treatment some years ago at the Pennsylvania Hospital, and 
demonstrated its mode of action upon patients in the wards where 
he had long preferred the confinement of patients on their backs, 
whenever practicable. More recently, a very similar idea has been 
expressed and very fully explained by Dr. John H. Packard, in 
his Mutter lectures before the Philadelphia College of Physicians. 
In a paper (" On Fractures of the Upper Extremities," New York Med. 
Journ., Nov. 1866, pp. 93 to 105 inclusive) founded on these lectures, 
he attributes most of the displacing action to the serratus magnus and 
pectoralis minor, in addition to that of the weight of the limb, and 
recommends u carrying the scapula backwards" by " acting on the head 
of the humerus, either by a figure of 8 bandage, properly applied and 
bearing on the sound shoulder, the elbow being carried forwards and 
well supported, or by a cap of muslin or linen, so made as to embrace 
the upper part of the arm, and fastened in the same way." Dr. 
Packard refers also to the bandage described by Dr. J. C. Palmer, 
Surgeon U. S. N., in the American Journal of Medical Sciences for 
July, 1863, as *\ a very comfortable contrivance for this purpose." 

Dr. Hartshorne is disposed to regard other large muscles of the chest 
and shoulders as more or less concerned in aiding that of the two 



FKACTUEE OF THE HUMERUS. 



409 



particularly mentioned, especially when an axillary pad is nsed to 
irritate and distend the armpit, and he prefers a more decided action 
on the lower angle of the scapula, together with such pressure on the 
shoulder as may press it backwards without interfering with the pres- 
sure upwards and outwards. The action of pressure upon the angle 
of the scapula in restoring the shoulder and reducing the fracture by 
extension of the outer fragment is very well shown upon a slender 
child of from five to ten years of age in whom the parts are well 
exposed and the weight of the limb is slight. It was repeatedly 
shown in .this way by Dr. Hartshorne at the Pennsylvania Hospital; 
but although to some extent realized and acted on by surgeons else- 
where, it does not appear to have been sufficiently enforced. The 
same principle of treatment was unquestionably carried out, without 
its being recognized, in the apparatus of Hippocrates, J. L. Petit, and 
Guillou, possessing interscapulary pads. 

Other forms of apparatus have been brought into notice recently, 
and used with success in the hands of their inventors. Among these 
we shall mention Hinton's "yoke splint" modified by Day, Welch's 
and Bartlett's apparatus. 

Fracture of the Humerus. — The humerus may be broken in 
any part of its length, and in order to convey a clear idea of the 
nature, causes, and treatment of this injury as it is seated in different 
localities, the subject requires consideration under distinct heads; 
and first, commencing above, we shall describe — 

1. Fracture through the Anatomical Neck of the Humerus {intra- 
capsular). — This form of fracture is caused by direct blows or falls 
upon the shoulder, or gunshot. Its direction is 
such that that portion of the head incrusted with 
cartilage is separated from the shaft of the bone ; it 
does not generally suffer any displacement, though 
in certain recorded cases the upper fragment has 
been found more or less twisted out of position, 
and impacted into the cellular substance of the 
tubercles. 

Symptoms. — The arm will be found of the same 
length as the opposite one, unless there is consider- 
able impaction, in which case there will be some 
shortening ; the elbow hangs by the side, and the 
patient can move the arm pretty freely. By press- 
ing the humerus towards the glenoid cavity, and 
rotating it, crepitus may be produced ; a very slight 
depression will be observed beneath the acromion. 

Treatment. — No splints will be required in the 
case ; the arm should be brought to the side, and 
the forearm supported in a sling. If the head of 
the bone becomes necrosed, it must be removed. 
This result will most frequently occur in those cases in which the head 
of the bone is split into a number of fragments by lines radiating 
from its centre. 

2. Fracture through the Tubercles of the Humerus (extra-capsular). — 
The tubercles comprehend the space included between the anatomical 



327. 




Fracture of the anatomi- 
cal neck. 



410 SPECIAL FEACTUKES. 

and surgical necks. This is a rare form of fracture, and generally 
results from direct blows applied to the shoulder. 

Symptoms. — There will not usually be found any shortening, though, 
as in the previous case, the fragments may be impacted, when accurate 
measurements with the tape-line will show perhaps a little ; displace- 
ment does not often occur, nor are the functions of the arm impaired, 
unless the muscles be badly bruised. By rotating the arm, crepitus 
may be perceptible to the hand placed upon the shoulder ; the arm 
hangs by the side naturally, and there will be no depression beneath 
the acromion. 

Treatment. — No apparatus is usually required, except to place the 
limb by the side and support it in a sling. If there should be marked 
displacement, however, either Erichsen's or Welch's splint may be 
applied. Local inflammation should be combated by appropriate anti- 
phlogistic measures. 

3. Vertical Fracture of the Head of the Humerus, separating the 
Greater Tubercle (extra-capsular). — In this fracture the greater tubercle 
is separated from the head of the humerus, and is generally somewhat 
displaced under the coracoid process. It is caused by blows upon the 
front of the shoulder. 

Symptoms. — The arm will preserve its normal length, and, barring 
the effects of the injury upon the muscles, it will possess the power 
of pretty free motion in every direction, and the hand can be placed 
upon the opposite shoulder. The elbow rests alongside of the body, 
or perhaps may incline a little backwards. The tubercle may be felt 
beneath the coracoid process, and its displacement increases the antero- 
posterior diameter of the upper end of the humerus. A slight de- 
pression may be observed beneath the acromion, and if the tubercle 
is fixed with the fingers, while the arm is being rotated, crepitus may 
be elicited. 

Treatment — Combat local inflammation, place the forearm in a sling, 
and confine the arm to the chest with a few turns of a roller. 

4. Fracture of the Surgical Neck of the Humerus (Fig. 328). — The 
"surgical neck" of the humerus embraces the space extending from 
the base of the tubercles to the insertions of the latissimus dorsi and 
pectoralis major. 

Fracture of this portion is the most common form of this kind of 
injury affecting the upper extremity of the humerus. 

It is met with in childhood and adult age ; in the former case the 
line of fracture will generally correspond with that of the epiphyseal 
junction. 

Causes. — The most frequent cause is direct injury applied to the 
shoulder ; sometimes it results from falls upon the elbow and hand, 
and Vidal records a case in which it proceeded from muscular action. 

Symptoms. — There will not generally be found a complete displace- 
ment of the fragments from each other, either in consequence of the 
close connection of the long head of the biceps to them, or from their 
being impacted, so that under these circumstances no shortening will 
be encountered. Sometimes, however, the reverse occurs, the supra- 
spinatus, infra-spinatus and teres minor muscles draw the upper frag- 



FRACTURE OF THE HUMERUS. 



411 



Fig. 328. 




ment forwards and outwards, while the lower one, obeying the action of 
the pectoralis major, latissimus and teres major, will be pulled inwards, 
and subsequently upwards towards the coracoid process by the triceps, 
biceps, and coraco-brachialis. In this case the arm will be more or 
less shortened. 

Although the above described displacement is the most common, 
yet there are recorded examples where the ends of both fragments 
have been thrown inwards, forwards or out- 
wards. Both Desault and Dupuytren have 
seen the lower piece projecting outwards, 
under the deltoid, and the former surgeon 
states that it has even pierced that muscle, 
and appeared externally. 

Where the fragments are not separated 
crepitus may easily be developed by mov- 
ing the arm in various directions ; there 
will be some slight depression below the 
acromion, or at least some want of fulness 
of the deltoid. The patient will be gene- 
rally unable to place his hand upon the 
opposite shoulder unless the fragments mu- 
tually sustain each other by contact or im- 
paction. In this latter condition of the 
bone its head will be found to move con- 
sentaneously with the shaft, while in a com- 
plete separation this will not be the case, 
the fingers can feel the head motionless in 

the glenoid fossa in whatever direction the arm may be moved. The 
position of the arm is also different in these two conditions, hanging 
vertically against the chest, when the fragments are not displaced, and 
sloping a little outwards with the elbow away from the chest when 
they are. 

Prognosis. — This injury requires that all the circumstances of the 
case should be carefully examined before a prognosis is given. There 
is often a good deal of difficulty encountered in maintaining the frag- 
ments in contact, and deformity and impairment of the functions of the 
limb result. 

It has been denied by some surgeons that bony union ever occurs 
at this point, but they say that the upper fragment becomes hollowed 
out into a cup-shaped cavity, which receives the upper end of the lower 
one, and thus forms a sort of artificial joint. Accurate observation 
has, however, in a number of instances, established the occurrence of 
bony union after fracture of the surgical neck. 

Treatment. — To reduce the fracture let an assistant fix the shoulder 
while another assistant makes the extension by seizing the middle of 
the forearm, bent at right angles, in one hand, and the wrist in the other; 
the surgeon will then endeavor to restore the displaced fragments to 
their normal position by pressure with his fingers. J. L. Petit directs 
the arm to be held at right angles with the body, while the extension 
is being made. 

In those cases where there is little or no displacement of the frag- 



Fracture of the surgical neck of the 
humerus. 



412 SPECIAL FRACTURES. 

ments, a simple sling for the forearm and a few turns of a roller, to con- 
fine the limb to the chest, will be all that is required. 

In other instances, however, where they are constantly and obsti- 
nately disposed to assume an abnormal position, it will tax the surgeon's 
skill to the utmost to maintain the reduction with his apparatus. 

Desault was in the habit of employing a bandage consisting of the 
following pieces : 1st. Two long rollers from two and a half to three 
inches wide. 2d. A wedge-shaped pad long enough to extend from 
the axilla to the elbow, and three or four inches thick at its base. 3d. 
Three splints from two and a half to three inches wide, two of which 
should be of the same length as the humerus, the third one shorter. 
4th. A sling to support the forearm, and sufficiently long so as not to 
lift the arm. 5th. A towel to inclose the whole apparatus and chest. 

In applying it, after the reduction has been effected, and an assistant 
still keeping up extension, the surgeon takes one of the rollers moistened 
in a dilute solution of the acetate of lead, to prevent its slipping, con- 
fines its initial extremity to the upper part of the forearm, and then, 
by circular and reverse turns, ascends the arm to the shoulder, over 
which the roller is passed to make two oblique turns under the sound 
axilla ; the roller is then held by an assistant. 

The first splint with its pad is placed upon the front of the arm 
extending between the bend of the elbow and the acromion; the 
second splint upon the outside of the arm, reaching from the external 
condyle to the acromion ; and the third upon the back of the arm, 
reaching from the olecranon process to the margin of the axilla. 

These splints are to be held in position by an assistant, while the 
surgeon takes the roller again and secures them by circular turns from 
above downwards. 

The pad is now to be arranged in the axilla, and pinned to the arm- 
bandage, care being taken to place its base upwards if the fragments 
are displaced inwards, and exactly the reverse if they are pushed out- 
wards. 

The arm is then brought against the pad and secured to the chest 
by the second roller passing around the arm and chest, drawing its 
turns firmly below, and loosely above, if the fragments are displaced 
inwards, and the reverse in external displacement. 

The forearm is placed in the sling, and the whole apparatus is enve- 
loped in the towel. 

The method of Desault is a very good one, and in several parts of 
Europe is preferred to any other. 

Sir A. Cooper recommends that a roller be applied from the elbow 
to the shoulder, splints to the outer and inner sides of the arm, and 
that these be confined by another roller. A cushion is placed in the 
axilla to throw the head of the humerus outwards, and the arm sup- 
ported in a long sling, for, he says, if the elbow is raised, the bones 
will overlap and the union will be deformed. 

Mr. Fergusson advises the bandages seen in Fig. 329, both for frac- 
ture of the surgical neck of the humerus, and for that of the tubercle 
and anatomical neck. It is applied by drawing down the lower frag- 
ment, and keeping the upper one in place by a small pad in the axilla ; 



FRACTURE OF THE HUMERUS. 



413 




Apparatus for fracture of surgical 
neck of the humerus. 



A 



a splint, about two inches and a half wide, 
reaching from the acromion to the elbow, 
is placed upon the outside of the arm and 
secured by a roller extending from the 
fmsrers to the shoulder. The arm is then 
brought to the side and confined to the 
chest by circular turns : the hand is sup- 
ported in a sling. 

In order to prevent the bandage being 
deranged, when it is necessary to retain it 
a long time, he suggests that the roller be 
moistened with a thick solution of starch 
or dextrine before its application. 

Mr. Erich sen, in managing these fractures 
of the upper extremity of the humerus, found 
a very convenient apparatus " to consist of a 
leathern splint about two feet long by six 
inches broad, bent upon itself in the middle, 
so that one-half of it may be applied lengthwise to the chest and the 
other half to the inside of the injured arm, the angle formed by the 
bend, which should be somewhat obtuse, being well pressed up 
into the axilla." In this way, he says, the tendency of the lower 
fragment to displacement inwards is corrected and the limb well 
steadied. 

Welch's shoulder-splint (Fig. 330), or a splint prepared in the 
same form, of leather, gutta-percha, felt, or pasteboard, is also 
an excellent contrivance for maintaining the reduction, and it is 
the one I generally employ for this purpose. 

In one case Mr. Tyrrell was obliged to keep the arm at right angles 
with the side, by means of a splint shaped like the 
letter L reversed. 

Eicherand, to correct the inward displacement of the 
lower fragment, advised that the elbow be carried to 
the front of the chest, the hand reposing upon the sound 
shoulder; it is bound in this position by the roller- 
bandage after the manner of Yelpeau's clavicle appa- 
ratus. 

Dupuytren placed a wedge-shaped pad in the axilla 
with its base downwards and confined the arm to the 
side with a roller bandage. 

5. Fracture of the Body of the Humerus. — The body 
of the humerus includes the space between the surgical 
neck and the condyles. 

Causes. — The causes of this fracture are direct vio- 
lence, counter-stroke from falls upon the elbow or hand, 
and muscular action. 

The nature of the displacement will depend upon 
the seat of the injury ; if it is above the insertion of 
the deltoid, the action of this muscle will draw the 
lower fragment upwards and outwards, while the upper piece will 



Fig. 330. 




Welch's shoulder- 
splint. 



414 SPECIAL FRACTURES. 

be depressed towards the chest by the latissiraus dorsi and pectoralis 
major. 

When the fracture is below this point, the deltoid will draw the 
upper fragment outwards and a little forwards, and the lower one will 
be lifted by the biceps and triceps upwards and inwards, though in 
most cases the weight of the limb below will prevent the latter dis- 
placement in a great measure. 

From the close connection of the triceps and brachialis anticus with 
the lower part of the humerus, a fracture in this portion will determine 
very little derangement of the fragments. 

Symptoms. — Crepitus may be easily developed by moving the frag- 
ments; the limb will generally be shortened, the cases in which it will 
not be observed are those where the line of fracture is transverse ; 
there will be preternatural mobility ; and the patient will be unable 
to use the limb. 

This fracture usually unites in six or seven weeks, with an average 
shortening of three-fourths of an inch, if it is an oblique one. 

Treatment. — To accomplish the reduction let an assistant fix the 
shoulder by grasping it in his hands ; the surgeon then takes hold of 
the arm and makes extension until the object is accomplished. 

The ordinary retentive bandage for fracture of the body of the 
humerus is applied in the following manner : with a roller envelop 
the arm moderately from the fingers to the shoulder, making four or 
five circular turns at the point of fracture ; take four padded splints 
of different lengths, one of which is to be placed upon the outside of 
the arm reaching from the acromion to the outer condyle, a second 
upon the inner side extending between the axilla and inner condyle, 
a third upon the posterior surface, and the last one upon the anterior. 
These splints are to be held by an assistant while the surgeon secures 
them either with the roller-bandage or with three strips of bandage 
tied around them at equal intervals. 

The inner splint is, to some extent, objectionable, as it may exer- 
cise injurious pressure upon the axillary vessels and nerves. It can 
be easily discarded without impairing the efficiency of the apparatus, 
the support given to the bone by it, being sustained by moving the 
anterior and posterior splints near each other. 

It has been suggested, to obviate this objection, to substitute for the 
inner splint an axillary pad ; but this does not accomplish the pur- 
pose, as it too will exert pressure upon those parts. 

Grooved splints are much more efficient than flat ones, and should 
always be used if they are attainable, inasmuch as they afford a more 
uniform support to the surface of the arm. 

Mayor's apparatus consists of a wire frame extending from the 
shoulder to the elbow, and embracing two-thirds of the circumference 
of the arm. This splint is to be padded with cotton batting, and 
secured to the limb with three pieces of bandage tied around them at 
equal intervals. 

Equally as efficient a splint may be made, in the same shape, of 
pasteboard, sole-leather, gutta-percha, wood, or tin. 

If the fracture is compound, that portion of the splint correspond- 



FRACTURE OF THE HUMERUS, 



415 



Fig. 331. 



ing with the injury may be removed, if it is required, to facilitate the 
application of the necessary dressings. 

If the patient is confined to bed, permanent extension may be em- 
ployed ; if the ordinary apparatus fails, by adhesive strips attached to 
the limb and connected with cords which may be fastened to the head 
and foot of the bed. 

Mr. Lonsdale used an apparatus for making extension, "consisting 
of a thin bar of iron, about an inch and a half wide, and long enough 
to extend from the axilla to the elbow, marked B in 
the wood-cut (Fig. 331). The lower end of the bar 
curves upwards underneath the elbow, so as to allow 
of this part of the limb fitting into it at C. This 
curve ends in a hook, E, for the attachment of a 
bandage ; and on the splint opposite to this hook is 
a small bar, placed across the perpendicular, also 
for the attachment of a bandage. To the upper ex- 
tremity of the splint a crutch is adapted, A, which 
fits underneath the axilla, and is movable up and 
down, being confined at pleasure by means of a small 
screw placed at the side of the vertical bar." It is 
placed upon the inner side of the arm, with the 
crutch in the axilla, and the elbow in its lower 
curved end, in which it is secured by a bandage 
passing about the hook and the little cross-piece 
opposite it. 

The apparatus of Hind is superior to the instru- 
ment of Lonsdale, inasmuch as it supports the limb 
more effectually. It is composed of a metallic splint 
to be placed upon the inner side of the arm, divided 
into two sections moving in opposite directions by a 
screw, and supporting at its upper extremity a crutch to rest in the 
axilla. The splint is movably articulated to a padded metallic gutter, 
to inclose the forearm. By this arrangement the arm can be sustained 
at any angle of flexion. The apparatus is secured to the limb by four 
straps — two above, to encircle the arm ; and two below, for the forearm. 

The "immovable apparatus," prepared with plaster, pasteboard, or 
starched bandages, and already fully described, will also, in some of 
these cases of fracture, be found to be an exceedingly elegant and 
efficient contrivance. 

6. Fracture of the Humerus through the Base of the Condyles. — This 
injury is produced by falls upon the elbow. The position of this 
fracture, which is generally oblique, is seen in Fig. 332. 

Symptoms. — The arm will be found semi-flexed and shortened; there 
is a preternatural mobility just above the elbow ; the olecranon pro- 
jects posteriorly; a hard tumor is formed in the bend of the elbow by 
the projection of the lower end of the upper fragment ; there will be 
an increase in the antero-posterior diameter of the elbow-joint ; and 
crepitus may be easily developed by moving the fragments. 

Diagnosis. — From the proximity of this fracture to the joint, it may 
be confounded with dislocation of both bones backwards. The main 




Lonsdale's apparatus 
for fracture of the hu- 



416 



SPECIAL FRACTURES, 
Fig. 332. 




Fracture at the base of the condyles. 

features of the two injuries will be found contrasted in the following 
table : — 



Fracture. 
Falls upon the elbow. 

Preternatural. 

Present. 

Easy by extension, bones be- 
coming again displaced 
when it is removed. 

Diminished. 



Unchanged. -J 

Prominence of the elbow in- ") 
creased by extension of the > 
forearm. ) 

Tumor formed by lower end *| 
of upper fragment in the | 
bend of the arm not large, }■ 
and above the fold of the | 
elbow. J 



Cause, 

Mobility. 
Crepitus. 

Reduction. 

Length of humerus, 
measured between 
condyle and acro- 
mion. 

Relation of apex of 
the olecranon with 
the condyles. 

Prominence of the el- 
bow. 



Tumor in bend of the 
elbow. 



Dislocation. 

Falls upon the palms of the 
hands with arms extended. 

Much decreased. 

Absent. 

More difficult, bones not dis- 
posed to become displaced 
after reduction. 



Not diminished. 



y It is much above. 

[Prominence of the elbow di- 
minished by extension of 
the forearm. 

r 

{ Tumor very prominent, and 
) below the fold of the elbow. 



Prognosis. — Union occurs in from seven to eight weeks, commonly 
with some shortening, from a half to three-quarters of an inch. After 

the removal of the apparatus, the 



Fig. 333. 




Physick 8 



plints. 



functions of the elbow will not be 
fully restored until after the lapse 
of several months. 

Treatment. — The reduction of 
the fracture is effected by exten- 
sion and counter-extension in the 
manner pointed out above. 

For the purpose of maintaining 
the fragments immovable, the late 
Dr. Physick recommended two an- 
gular splints (Fig. 383), which keep 
the forearm flexed at right angles. 



FRACTURE OF THE HUMERUS 



417 




In applying the apparatus, the fracture is to be reduced, and a 
roller put on the limb from the hand to the shoulder; the splints are 
padded, laid on the limb, and secured in position by the roller passing 
around them from above downwards. 

These splints may be made of wood or pasteboard, and should be 
an inch and a half wide, the part applied to the arm extending from 
near the shoulder to the elbow, and that to the forearm from the elbow 
to the ends of the fingers, so as to prevent any motion in the hand ; 
a handkerchief, passing around the neck as a sling, supports the weight 
of the forearm. 

Sir A. Cooper, in treating this injury, directs the arm to be bent and 
drawn forwards to effect replace- 
ment ; " and then a roller should Fi S- 334 - 
be applied while it is in the bent 
position. The best splint for it 
is one formed at right angles, the 
upper portion of which is to be 
placed behind the upper arm, and 
the lower portion under the fore- 
arm; a splint must also be placed 
upon the forepart of the upper 
arm, and straps to confine both ; 
and the arm kept in a bent po- 
sition by a sling (Fig. 334). 

" In a fortnight, if the patient 
be young, passive motion may 
be gently begun to prevent the 
occurrence of anchylosis ; and in the adult, at the end of three weeks, 
a similar treatment is to be pursued." 

Mr. Fergusson advises that a piece of pasteboard, gutta-percha, 
or strong bend-leather, of the shape similar to that shown in Fig. 
335, should be applied on one 

surface of the elbow, another of Fig. 335. 

a like kind on the opposite, and 
both should be retained with a 
bandage, which should extend as 
here exhibited, from the hand to 
the middle of the arm. The 
splint for the inner side should 
have a round hole or deep hollow 
opposite the condyle, so that it 
may fit all the better without in- 
jurious pressure. Sometimes, if 
bandages are thus applied, it 
will be found that the fingers 
become cedematous, when they 
also may be enveloped in narrow 
rollers. 

Dr. Hamilton prepares an ap- 
paratus for this injury by moulding to the shoulder, arm, and forearm, 
27 



Sir A. Cooper's splint for fracture of humerus. 




Fergusson's mode of treating fracture above the. 
condyles. 



418 



SPECIAL FRACTURES. 



Fig- 336. as far as the base of the fingers, 

a sheet of gutta-percha, as seen 
in Fig. 336. 

In applying the splint, pad it 
neatly with cotton-batting so as 
to make the pressure uniform 
everywhere, put it on the limb, 
and secure it in position by a 
roller bandage. 

As early as the eighth day he 
directs that the arm be removed 
from the splint and gentle pas- 
sive motion imposed upon the 
joint, to prevent anchylosis ; this 
must be repeated as often as 
every second or third day. 

In the construction of the fore- 
going apparatus, the arm and 
forearm splints are immovably 
connected at the elbow. There 
are others in which provision is 
made for obtaining motion at 
the elbow-joint. Of these the 
one I prefer to all others, and which, in my opinion, possesses all the 
advantages derivable for an elbow splint is that of Dr. Bond. It con- 
sists of two metallic gutters, one for the arm and the other for the 
forearm, connected together upon one side by a lateral bar of iron 
jointed at the elbow ; the motions of the joint being controlled by a 
screw. 

As seen in Fig. 337, the bar is connected with the gutters in such a 




Hamilton's «lbow splint. 



Fig. 337. 




Bond's elbow splint. 



manner that the former may be removed at pleasure, and adapted to 
gutters of any size. 

In using the apparatus, the splint must be padded with cotton- 



FRACTURE OF THE HUMERUS. 



419 



Fig. 338. 



batting, and the arm laid upon it ; then apply a roller bandage from 
below upwards. 

At the end of seven or eight days, by simply loosening the screw 
at the elbow, passive motion may be imposed upon the joint without ' 
disturbing the apparatus in the least. 

The apparatus of Welch (Fig. 338) is made in a similar manner to 
that of Bond's, gutta-percha being substituted for metal in making 
the splints. The metallic joints 
may be removed at will, and 
put upon other splints. 

Dr. Kirkbride's elbow splint 
consists of two short splints 
connected at the elbow by a 
hinge. The arrangement for 
checking the joint movement 
is formed of a swivel eye pass- 
ing through the top of the 
splint, riveted upon its pos- 
terior edge, and a row of me- 
tallic eyes, two inches apart, 
between which there are series 
of small holes in the wood upon 
its anterior edge ; by means of 
a wire connected with the 
swivel eye above, and hooked 
in the eyes and holes below, 
the arm may be bent to any 
angle (Fig. 339). Welch . s elbow 8plinfri 




Fig. 339. 




Kirkbride's elbow splint. 

This splint is to be padded and applied upon either the inner or 
outer side of the limb with a roller bandage. 

The splints of Rose and Day are constructed in the manner seen in 
Figs. 340 and 341. They are made of wood, and carved in the shape 
of the surface of the limb ; they are much less convenient and efficient 
than the apparatus described previously. 

In compound fracture near the elbow I have, in several instances, 
used the apparatus recommended by Mayo with advantage (Fig. 342). 
It consists of " two splints joined together by two small bars so as to 



420 



SPECIAL FKACTUKES, 
Fig. 340. 



Fijr. 341. 




Rose's splint. 



Day's splint. 



leave a space between them for the elbow to fit into. One of the 
splints, B, seen in the wood-cut, is made for the back part of the arm 

Fig. 342. 




Mayers apparatus for fracture. 

to lie upon, while the other, (J, is for the forearm ; the second splint 
terminates in a horizontal portion, D, for the hand to rest upon ; the 
intervening space, A, is formed by the two lateral bars, which are 
slightly curved outwards, to prevent pressure upon the joint. 

7. Fracture through the Lower Epiphysis of the Radius. — Dr. Eobert 
Smith, of Dublin, describes a fracture occurring in young persons be- 
fore the ossification of the lower epiphyseal centres to the shaft of the 
humerus has taken place, which differs from the supra-condyloid frac- 
ture in that the line of separation runs below the condyles, which pro- 
perly belong to the diaphysis of the bone. 

He remarks that " the symptoms which belong to it in common with 
fracture above the condyles are the following : Shortening, crepitus, 
the removal of the deformity by extension, and its tendency to recur 
when the extending force is relaxed ; the presence of an osseous tumor 
in front of the joint ; the increase in the antero-posterior direction of 
the elbow. 

" It differs from supra-condyloid fracture in the greater transverse 
breadth and regular convex outline of the anterior tumor; in the ex- 
istence of two tumors posteriorly ; in the loss of the normal relation 
of the olecranon to the condyles. 

'• It resembles dislocation of both bones of the forearm backwards, 
in the following particulars : — 

" The transverse diameter of the anterior tumor is the same in each 



FRACTURE OF THE HUMERUS. 



421 



Fig. 343. 




Fracture at the base of and 
between the condyles. 



case ; so also is the antero-posterior breadth of the elbow ; and in both 
the olecranon ascends above the condyles, the limb is shortened, and 
two osseous prominences can be distinguished posteriorly. It differs, 
however, from luxation in the existence of crepitus, the tendency of 
the deformity to recur, in the anterior tumor being destitute of trochlea 
and capitulum, and in the circumstance of the two posterior tumors 
being nearly upon the same level." 

8. Fracture through the Base of the Condyles with a Fracture running 
between them into the Joint. — This variety of fracture is seen in Fig. 
343. It is caused by falls and blows upon the 
elbow. 

Symptoms. — The arm will be shortened ; the 
elbow increased in width ; ulna and radius dis- 
placed backwards and upwards ; preternatural 
mobility ; and crepitus may be elicited when 
the ulna is drawn down into place, and the con- 
dyles are rubbed against each other. 

Treatment. — Whatever method of treatment 
may be pursued in this fracture, anchylosis will 
be almost sure to follow. 

I have an interesting specimen of this frac- 
ture which I obtained from an arm amputated 
one year after the injury. The joint was anchy- 
losed, and there was a complete abolition of 
sensation and motion below the point injured. 

The line of fracture is exactly transverse ; the external condyle with 
the portion of trochlea attached is displaced backwards so that its an- 
terior border corresponds with a line running across the middle of 
the lower surface of the upper fragment. The internal condyle, with 
that part of the trochlea connected with it, is displaced upwards, its 
external edge lying beneath the inner edge of the external fragment, 
and united to the shaft of the humerus. 

The surgeon ought to replace the fragments as well as he can by 
having the limb extended, while with the fingers 
he presses them into their natural position. One 
of the elbow splints above described may then be 
applied. 

Desault recommends an apparatus which con- 
sists of two angular splints, one for each side of 
the arm, and two others for its anterior and pos- 
terior surfaces. These are to be accurately 
moulded to the elbow, then padded and secured 
to the arm with a roller bandage. 

9. Fracture through the External Condyle. — In 
fracture of the external condyle the line of sepa- 
ration passes from the external condyloid ridge 
beyond the capsular ligament downwards and 
inwards into the joint, as seen in Fig. 344. 

This injury is generally met with in children, Fracture of the external 
and results from blows or falls upon the elbow. condyle. 



Fig. 344. 




422 SPECIAL FKACTURES. 

There will not usually be found much displacement of the fragment, 
in consequence of the support given to it by the surrounding muscular 
fibres ; there are cases, however, in which the condyle is displaced 
backwards, carrying along with it the head of the radius. 

Symptoms. — Pain in the movements of flexion and extension; pro- 
minence of the fractured condyle ; crepitus developed by rotating the 
forearm; and when the forearm is extended, it is sometimes deflected 
towards its radial margin. 

Treatment. — Place the forearm at right angles with the arm, and 
apply one of the rectangular splints already described. It may be 
necessary, in rare cases, in order to keep the condyle in its normal 
position, to adopt the extended posture for the limb. At the end of 
seven or eight days remove the splint, and exercise the joint gently 
every two or three days. 

Whatever treatment is pursued, anchylosis will be often found fol- 
lowing the injury. 

10. Fracture through the Internal Condyle. — This variety of fracture is 
met with almost exclusively in childhood. It is 
Fig. 345. caused by falls upon the point of the elbow. The 

line of fracture passes usually from a point about 
half an inch above the epicondyle outwards into 
the joint, as seen in Fig. 345. The fragment is 
generally displaced upwards, backwards, and a 
little inwards, though it may occur forwards and 
inwards. I have a specimen in which the dis- 
placement has taken place directly upwards. 

Symptoms. — The ulna being carried backwards 
with the condyle it will cause a projection of the 
olecranon when the forearm is extended; the 
prominence disappearing again in flexing the 
limb. In extension also the end of the humerus 
will form a tumor in the bend of the elbow. If 
the finger be put on the condyle, by flexing and 
condyle."" extending the forearm, crepitus will be perceived. 

Treatment. — This fracture should be treated in 
the same manner as that of the outer condyle. The elbow should be 
inspected every day so as to watch the progress of the case, and to 
correct any undue or hurtful pressure upon the part. 

At the end of a week remove the splint, and begin to impose passive 
motion upon the joint, and repeat it every two or three days. 

As in the previous variety of fracture, anclrvlosis will often attend 
the best conducted treatment. 

11. Fracture through the Internal Epicondyle. — The little projection 
upon the inner condyle, called the epicondyle, may be broken by falls 
upon the inner side of the elbow. 

I saw a case with Dr. Stone, of Washington, in a boy fourteen 
years of age, who fell from a cart to the ground, striking upon the 
inner side of the elbow, where the skin was a little bruised ; the epi- 
condyle was displaced somewhat upward. The compress was placed 
above the displaced fragment, which could easily be brought down, 




Fracture of the internal 



FRACTURE OF THE RADIUS AND ULNA. 



423 



and confined by a figure of 8 bandage ; the arm was then placed in a 
rectangular splint of pasteboard. 

In seven days the splint was removed, and the joint exercised ; the 
treatment was continued for a few days longer, when the apparatus 
was entirely abandoned ; the boy recovered with all the functions of 
the limb intact. 

In most of the recorded cases of this injury the displacement of the 
fragment has been downwards. 

It will be proper to add here, that the treatment recommended in 
the above sections for fracture of the condyles is different from that 
pursued arid recommended by Dr. Warren, of Boston, who says that 
" in the treatment of fractures of the condyles of the os humeri, a 
course is usually recommended which he believes to be hurtful, inas- 
much as it favors the worst consequences of the injury, namely, loss 
of motion in the joint. By this mode of treatment, the fractured piece 
becomes sufficiently fixed to create partial anchylosis ; and there is so 
much pain afterwards in the proposed passive movements as to cause 
the omission of these measures until permanent stiffness takes place. 
The proper course in the management of these accidents, he conceives 
to be: 1st. To apply no splints, but in the earlier days to make use 
of the proper means to prevent inflammation. 2d. To accustom the 
patient to early and daily movements of flexion and extension. 
3d. When the action of the joint becomes limited, to overcome the 
resistance by force, and repeat it daily until the tendency of the joint 
to stiffen ceases." 

Fracture of the Eadius and Ulna (Fig. 346). Causes. — Fracture 
of both the radius and ulna results from direct blows upon the forearm, 
and from indirect force, the patient falling upon the palms 
of the hands, with the arms thrown forward. 

The fracture may be simple or comminuted, or com- 
pound, and is usually seated in the middle and lower 
thirds of the bones. The upper part of the ulna is 
stouter than it is elsewhere, and is covered with a thick 
layer of muscles, which amply protects it. These cir- 
cumstances explain the rarity of fracture in the upper 
third of the bone. 

Both bones are commonly broken at or near the 
same level, though the reverse may occur. The frag- 
ments may be displaced in any direction; that most 
often observed is where they are pushed either to the 
radial or ulnar side of the forearm ; they also may some- 
times approximate each other. There can occur but 
little displacement in the direction of the length of the 
bones in consequence of the connection of the inter- 
osseous ligament to their inner borders. 

Symptoms. — The symptoms are inability to pronate 
and supinate the forearm; preternatural mobility; de- 
formity at the seat of fracture; and crepitus by press- 
ing the fragments in opposite directions. 



Fig. 346. 



Prognosis. — In simple fracture of both bones, and 



Fracture iu the 
lower third. 



424 SPECIAL FRACTURES, 



under proper treatment, union will take place between three and five 
weeks, without apparent deformity. 

It may, however, be delayed in rare cases for months, or even 'may 
not take place at all. Sometimes it happens that one or the other 
bone unites promptly in the usual time, while union in the other is 
delayed. 

Improper dressings can destroy the functions of pronation and supi- 
nation by pressing the radius and ulna together while the consolida- 
tion is being effected. 

Treatment. — The reduction is accomplished by making extension 
and counter-extension from the wrist and elbow, while the surgeon 
presses with his fingers upon the front and back of the forearm, over 
the interosseous space, so as to force the bones asunder. 

In applying the retentive apparatus it was formerly the custom to 
put a bandage upon the limb from the hand to the shoulder before 
the splints were laid on. It is now very properly discarded, inasmuch 
as the practice effected exactly what the surgeon endeavors to pre- 
vent — a drawing together of the radius and ulna. 

The ordinary apparatus consists of two flat splints of greater width 
than the forearm, and padded in such a manner that they may be a 
little thicker along the centre than at the margins ; they should be of 
unequal length, the anterior reaching from the bend of the elbow to 
the tips of the fingers ; and the posterior, from the elbow to the roots 
of the fingers. These splints are laid upon the forearm, and confined 
by a roller bandage. The arm ought to be examined every day, to 
be sure that no injurious pressure is exercised at any point. 

Some surgeons, instead of padding the splint, employ graduated 
compresses beneath them in order to force the muscles towards the 
interval separating the bones. In this case, as suggested by Nelaton, 
the compresses ought to be short, so as not to press upon the ulna 
and radial arteries. 

When the splints have been properly secured to the forearm it will 
be advisable, if it is possible, to put the forearm in a posture of supi- 
nation, and projecting in front of the body, while the elbow rests 
against the side. In this position the fragments will be more easily 
brought together, and the bones will encroach less upon the interos- 
seous space, thus rendering any impairment of the function of supi- 
nation, when consolidation occurs, much less likely to follow ; there 
will also be less tendency to lateral distortion. 

Although these advantages are manifest, yet there are some sur- 
geons who have overlooked them, and directed the forearm to be 
placed midway between supination and pronation, with the plane of 
the hand vertical. 

In compound fractures it may be necessary to put the forearm in a 
posture of pronation; in such cases the limb may be laid upon a sim- 
ple flat board, and loosely connected to it, above and below, by a few 
turns of a roller. 

If the person is able to walk about, the apparatus of Mayor may be 
employed, which consists of a board a little longer than the forearm 






FRACTURE OF THE RADIUS. 



425 




Mayor' 



apparatus for fracture of the 
forearm. 



and hand, a cushion, a cord for suspension, 
and three cravats. "The fracture being 
reduced, the forearm is placed upon the 
cushioned boards a, b (Fig. 347), which is 
immediately suspended from the patient's 
neck by means of the arc-loops e, e, the 
ring /, and the cervical cravat g. The 
second cravat, c, is now placed under the 
wrist, and crossed upon the back of the 
hand, the tails being then made to embrace 
the cushioned board, and knotted at the 
anterior border, as represented at h. The 
third cravat is made to pass around the 
apparatus at its upper part, so as to con- 
fine the corresponding portion of the fore- 
arm, and is then knotted as the other. If it be necessary to counteract 
any lateral displacement, a fourth cravat may be made use of, to serve 
as a traction ligature ; which will of course be knotted at the inner 
margin of the suspension-board." 

If the patient be confined to bed, the apparatus may be supported 
by a cord hanging from the ceiling, or from an upright fastened to 
the bedstead. 

Fracture of the Eadius. — Fracture of the radius is more frequent 
than that of both bones of the forearm, or of the ulna alone, and the 
right is more often broken than the left. 

There are three varieties of this fracture which we shall consider 
separately. 1st. Fracture of the upper extremity. 2d. Fracture of 
the shaft. 3d. Fracture of the lower extremity. 

1. Fracture of the Upper Extremity of the Radius. Causes. — Frac- 
ture of the upper extremity of the radius is the least frequent of the 
three varieties, and is produced by direct blows upon the part, and by 
counter-stroke. 

The line of fracture may be above or below the insertion of the 
biceps muscle. 

Symptoms. — In fracture through the neck of the radius, which is 
exceedingly rare, the biceps will draw the superior end of the lower 
fragment upwards, forwards, and inwards, while the supinator radii 
brevis will displace the head slightly outwards, perhaps, forming a 
prominence in front of the elbow; there will be loss of voluntary 
supination and pronation ; if the surgeon grasps the elbow in his left 
hand pressing with the thumb upon the head of the radius, the latter will 
not be found to move when he supinates and pronates the forearm 
with his right; the hand will be found in a prone position, and crepitus 
will be perceived during the movements executed in the examination. 

If there is much tumefaction, the diagnosis will be exceedingly dif- 
ficult, if not impracticable. 

Treatment. — Bend the forearm at right angles to relax the biceps, 
place a rectangular splint upon the posterior surface of the limb, and 
a compress in the bend of the elbow, and then confine the whole with 
a roller bandage ; support the arm in a sling. 



426 



SPECIAL FRACTURES 




Fracture of the shaft of the radius. 



2. Fracture of the Shaft of the Radius. — Fracture of the shaft of the 
radius occurs most frequently in its lower third. 

Causes. — Direct injury to the bone, and by falls upon the palms or 
backs of the hand when the arm is stretched forward. 

The displacement of the fragments that occur will depend in a great 
measure upon the nature and direction of the force. They may both 

be depressed towards the 
Fig- 348. ulna, or be thrown forwards, 

backwards, or outwards. 

The Fig. 348 shows the 
upper fragment displaced 
forwards by the action of the 
biceps and pronator radii 
teres, while the lower one is 
drawn towards the ulna by 
the pronator quadratus, and 
supinator longus. 

Treatment. — The splints 
required in the treatment of this fracture are the same as those de- 
scribed for fracture of both bones. 

3. Fracture of the Loiver Extremity of the Radius. — Fracture of the 
lower extremity of the radius occurs most frequently within an inch 
and a half of the articulating surface, and constitutes what is known 
as " Colles' fracture." 

The line of separation is generally horizontal, though it may be 
oblique from above downwards and from behind forwards, or the 
reverse. 

In the injury known under the name of "Barton's fracture" this line 
runs upwards and backwards from the joint, separating a greater or 
less extent of the articulating surface of the radius from the shaft. 

Cause. — This fracture always results from falls upon the palm or 
back of the hand while the arm is outstretched. 

Symptoms. — The characteristic appearance of this injury is seen in 
Fig. 349. The lower fragment of the radius is carried backwards, up- 

Fig. 349. 




Fracture of the radius near its lower end. 



wards, and outwards by the extensors of the thumb and the supinator 
longus displacing the carpus and metacarpus in that direction, and 
forms a tumor upon the back of the wrist ; above this there is a well- 
marked depression. In front another prominence is observed extend- 
ing about one-third up the forearm ; the hand falls towards its radial 
margin, while the styloid process of the ulna projects prominently in 



FRACTURE OF THE RADIUS. 



427 



Fie. 350. 




the direction of the palm ; by grasping the hand and moving it, 
crepitus may be made manifest. 

Treatment. — The reduction of the fracture is accomplished by making 
extension from the hand, and at the same time exercising pressure 
upon the tumor at the back of the wrist from behind forwards. 

The indication to fulfil in the use of apparatus is manifest, namely, 
to incline the hand to the ulnar border of the forearm and retain it in 
that position. 

For this purpose Dupuvtren recommended a splint made of a bar 
of iron (Fig. 350). about an inch wide and of the length of the forearm, 
and which, at its lower extremity, 
opposite the part corresponding 
with the wrist, curves downwards 
in a semi-circle, to the concavity 
of which some buttons are placed 
at equal distances. 

To apply the splint, place be- 
neath it upon the ulnar border 
of the forearm a narrow pad, ex- 
tending from the styloid process 

of the ulna to the elbow, and about one inch thick below, gradually 
tapering upwards ; then with a roller secure it to the limb ; arriving at 
the wrist make turns around the radial border of the hand and curved 
extremity of the splint, so as to maintain the hand in a position of 
forced adduction. 

Sir A. Cooper, in treating this fracture, applied a roller from the 
wrist to the elbow, and then two padded splints upon the anterior and 
posterior surfaces of the forearm, reaching from the elbow to the roots 
of the fingers ; the splints were secured to the limb by a second roller, 
beginning at the wrist. The forearm is now placed in a sling in a 
position midway between pronation and supination, so that the weight 
of the hand, moving freely between the splints, may adduct it. 

The method pursued by Nelaton was to apply a pistol-shaped splint 
(Fig. 351), well padded, to the dorsal surface of the forearm, reaching 

Fig. 351. 



Dupuytren's apparatus for fracture of the radius 
near the wrist. 




Xelaton's splint for racture of the radius. 

from the tips of the fingers to the elbow, and a straight one upon its 



428 



SPECIAL FRACTURES, 



palmar surface extending from the wrist to the elbow; a compress is 
to be placed beneath the curved splint and over the lower fragment, 
while the straight splint must be placed opposite the upper fragment, 
and also along its radial margin, to prevent the tendency which this 
part of the radius has to pronation. The splints are secured to the 
arm with a roller bandage. 

Another plan, recommended bj this distinguished surgeon, is the 
following : Place a square compress over the lower fragment at the 
back of the forearm, and a long compress upon its palmar surface 
reaching from the elbow to a point just above the lower margin of the 
prominence upon that side. Upon these compresses lay two straight 
splints extending from the wrist to the elbow, and confine them by a 
roller bandage or three broad strips of adhesive plaster ; the hand is 
thus left free to take a position of adduction by its own weight, while 
the compresses force the fragments in directions opposite those of their 
displacement. 

The splint devised by Dr. Bond, of Philadelphia, is also an efficient 
one in the treatment of this injury; it is prepared in the following 
manner: Cut from any sort of light wood a splint having the shape 
of that seen in Fig. 352, and long enough to extend from the elbow 

Fig. 352. 




Bond's splint for fractured radius. 

to the second joints of the fingers. To its lower extremity fasten with 
screws or nails a cylindrical piece of wood B, which is intended to sup- 
port the palm when the forearm reposes on the splint. 

To make it more comfortable narrow strips (D) of binders' board or 
leather may be nailed to the lateral edges of the splint, Fig. 353. 

Fig. 353. 




Bitnd's splint with strips attached. 



The apparatus is applied by padding the splint with cotton-batting 
or flannel, and laying the forearm with the fracture reduced upon it; 
above and below the point of injury, a compress of suitable thickness 
is to be placed, and then the whole dressing inclosed with a roller 
bandage. 



FKACTUKE OF THE KADIUS. 



429 



Should the elegant splint of Dr. Bond not be attainable, one some 
what similar in form may be prepared as directed by Dr. Hays, from 
any sort of wood that may be at hand ; it is cut into the shape seen 
in Fig. 354. As a substitute for the cylindrical piece of wood, a 

Fig. 354. 




Hays' splint for fracture of radius. 

common roller can be used, secured to the end of the splint by a 
bandage, as shown in the cut. 

Dr. E. P. Smith has modified Bond's splint in such a manner that 
one splint may be employed upon either arm. This object is attained 
by articulating the palm-block D (Fig. 355) with the guttered arm- 
Fig. 355. 




Smith's modification of Bond's splint. Back view. 



splint A, by means of a circular joint which may be fixed at any 
angle by a thumb-screw placed upon its posterior surface. 

The range of motion of the palm-block is indicated in Fig. 356 by 
the dotted arc C 0. 



Fig. 356. 



r 




Same splint. Front view. 



The apparatus employed by Dr. Hamilton is directed to be pre- 
pared extemporaneously from a wooden shingle, cut into the requisite 



430 



SPECIAL FRACTURES, 



Fig. 357. 




Hamilton's splint for fracture of the radius. 



shape and length (Fig. 357), the length being obtained by measuring 
from the front of the elbow-joint, when the arm is flexed to a right 

angle, to the metacarpophalangeal ar- 
ticulations. It ought, indeed, to fall 
half an inch short of the bend of the 
elbow, to render it certain that it 
shall make no uncomfortable pressure 
at this point; and the direction to 
measure with the arm flexed is of 
sufficient importance to warrant a 
repetition. The breadth of the splint 
should be, in all its extent, just equal to the breadth of the forearm in 
its widest part, so that there shall be no lateral pressure upon the 
bones. If the splint is of unequal breadth, the roller cannot be so 
neatly applied, and is more likely to become disarranged. Thus con- 
structed, it is to be covered with a sack of cotton cloth, made to fit 
lightly, with the seam along its back, and afterwards stuffed with 
cotton-batting or with curled hair. These materials may be passed 
in and easily adjusted, whenever they are most needed, from the open 
extremities of the sack. While preparing, the splint must be occa- 
sionally applied to the arm until it fits accurately every part of the 
forearm and hand, only that the stuffing must be rather more firm a 
little above the lower end of the upper fragment. The open ends of 
the sac are then to be neatly stitched over the ends of the splint. 
This splint is now to be laid directly upon the skin without any inter- 
mediate compresses or rollers. In all cases it is better to employ, 

also, at least during the first fort- 



Fig, 358. 




Apparatus applied. 



night, a straight dorsal splint, of 
the same breadth as the palmar 
splint, and of sufficient length to 
extend from the elbow to the 
middle of the metacarpus (Fig. 
358). This should be covered 
and stuffed in the same manner 
as the palmar splint, except that 
here the thickest and firmest part 
of the splint must be opposite the 
carpus, and the lower end of the 
lower fragment. It will answer 
the indications also a little more 
completely if, at this point, the 
padding is thicker on the radial 
than on the ulnar side. The ap- 
plication of the apparatus is effect- 
ed by restoring the fragments to 
place, in case of Colles' fracture, 
by pressing forcibly upon the back 
of the lower fragment, the force 
being applied near the styloid 
apophysis of the radius, the arm 



FRACTURE OF THE ULNA. 431 

is to be flexed upon the body, and placed in a position of semi-prona- 
tion, when the splints are to be applied and secured with a sufficient 
number of turns of the roller, taking especial care not to include the 
thumb, the forcible confinement of which is always painful and never 
useful. 

Dr. J. Ehea Barton recommended the application of two broad, 
straight, and padded splints to the dorsal and palmar aspects of the 
forearm, extending from the elbow to the tips of the fingers ; beneath 
the splints two compresses are placed, one over the posterior surface 
of the lower fragment, the other over the anterior surface of the upper 
one ; a roller bandage is used to secure the splint to the forearm. 

Colles also used straight splints. 

Prof. Fauger, of Copenhagen, discarding all sorts of splints in the 
treatment of this injury, advises the forearm to be laid upon a wedge- 
shaped support, inclining towards the patient, with the hand hanging 
over the perpendicular end or base of the support. 

Fracture of the Ulna. — The varieties of fracture of the ulna 
may be described under the following heads : 1st. Fracture of the 
olecranon process. 2d. Fracture of the coronoid process. 3d. Frac- 
ture of the body and lower extremity. 

1. Fracture of the Olecranon Process. Causes. — Fracture of the olecra- 
non process is generally caused by falls upon the point of the elbow, 
or by direct blows ; it is also occasionally seen to result from violent 
contraction of the triceps. 

The line of fracture may pass through any point of the process from 
the base to the apex, but it generally occurs midway between these points. 
Its direction is commonly trans- 
verse, occasionally oblique, either Fig- 359. 
from before downwards and back- 
wards, or from above downwards, 
and from behind forwards. 

The olecranon is displaced up- 
wards, or in the direction of the 
line of action of the triceps, pro- 
ducing an interval between it and 
the ulna from a few lines to two 
inches according to the extent of 

the laceration Of the tendinOUS in- Fracture of the olecranon process. 

sertion of that muscle. 

Symptoms. — The limb will be in a posture of semi-flexion, and the 
patient will be unable either to flex or to extend it. A depression will 
be observed above the point of the elbow caused by the absence of the 
olecranon and the tendon inserted into it; that process can be felt drawn 
up into its new position. If the arm is extended, the olecranon may be 
easily brought down, and, by rubbing it laterally against the ulna, 
crepitus will be perceived. To these symptoms are to be added pain 
and swelling at the seat of injury. 

Prognosis. — If the fragment is kept in contact with the ulna, bony 
union may occur, but in the majority of cases the cure is brought 
about by ligamentous union. 




432 



SPECIAL FRACTURES. 



Treatment. — Extend the forearm to relax the triceps, bring down 
the olecranon, and secure it in apposition with the ulna by an appro- 
priate apparatus. 

The method pursued by Sir A. Cooper was "to place a piece of 
linen longitudinally on each side of the joint ; a wetted roller is applied 

Fig. 360. 




Sir A Cooper's apparatus for fracture of the olecranon. 

above the elbow, and another below it ; the extremities of the linen 
are then to be doubled down over the rollers and tightly tied, so as to 
cause an approximation of the fragment ; thus the portions of bone 
are brought and held together ; a splint well padded is to be applied 
upon the forepart of the arm to preserve it in a straight position, and 
confined to it by a circular bandage." 

If there is much inflammation before applying this apparatus, it 
will be necessary to have recourse to leeches and cold water- dressings 
for two or three days. 

The apparatus of Mr. Amesbury consists of two belts, one fastened 
above the olecranon, and the other upon the forearm, which he con- 
nected together by lateral straps and buckles to draw the upper frag- 
ment down ; upon the anterior surface of the arm a guttered splint is 
to be applied to keep the limb fully extended. 

In an emergency, the plan recommended by M. Mayor may be pur- 
sued : The arm is placed in an extended position ; to its anterior sur- 
face a pasteboard splint is moulded (or a splint of any other sort may 
be used if the pasteboard is not at hand), extending from about three 
inches above the elbow to the tips of the fingers ; the olecranon is now 
brought in contact with the ulna, and above it is placed a compress, 

Fig. 361. 




Mayor's apparatus for fractured olecranon. 

secured in position by a cravat tied around it and under the arm, the 
tails of the cravat being permitted to hang towards the hand upon the 
back of the forearm ; another cravat is tied around the lower part of 
the splint and the metacarpus, when the tails of the two cravats are 
knotted together posteriorly at the middle of the forearm. 

Desault objects to placing the arm in an extended position (an ob- 
jection concurred in by both Yelpeau and Nelaton), and recommends 



FRACTURE OF THE ULNA. 433 

that the forearm be kept midway between semiflexion and complete 
extension by an angular splint. The reason assigned is, that in frac- 
ture of the olecranon at its base the extended position causes the bra- 
chialis anticus to draw the upper end of the ulna somewhat forwards, 
so that the fragments cannot be kept in a straight line ; and if union 
should occur under these circumstances, it will be at their posterior 
edges only, thus forming an open angle opposite the joint into which 
the substance effused for uniting the fracture will be thrown, and by 
its subsequent organization impede the motions of the elbow. 

After the splints have remained on the limb for three weeks they 
must be removed, and passive motion impressed upon the joint to 
prevent anchylosis. 

2. Fracture of the Coronoid Process. — Fracture of the coronoid process 
of the ulna is seen in Fig. 362. It is of extremely rare occurrence ; 
so much so, indeed, that there are but few unquestionable instances of 
the kind upon record. 




Fracture of the coronoid process. 

M. Kiihnholtz, of Montpellier, describes two varieties of the injury, 
the first consists in the simple knocking off of the top of the process 
either by direct force, or what is more frequent, by falls upon the 
palms with the arms thrown forward, the weight of the body being 
chiefly sustained upon the hypothenar margin of the hand. The in- 
jury is recognized by the inability of the patient to flex the arm 
until the reduction is effected, which is very difficult; by the presence 
of a small, hard, and freely movable body in front of the joint ; and 
lastly, by a sudden cracking felt by the person in the bend of the 
elbow at the moment of the fall. 

The second variety involves the base of the process, and is always 
produced by direct violence, and is generally accompanied by a dislo- 
cation backwards of the ulna, or a fracture of one or both of the bones 
of the forearm, and so much laceration of the soft parts that amputa- 
tion is often required. 

Fracture of this process cannot result from muscular action, inas- 
much as there are no fibres inserted into it that could exercise the 
required amount of force to effect it. The brachialis anticus is inserted 
at its base. 

Treatment. — Flex the forearm at right angles, and mould to the pos- 
terior surface of the limb a splint of gutta-percha, pasteboard, or plas- 
ter of Paris ; place a compress upon the fold of the arm, and then 
inclose the apparatus in a roller bandage from the hand upwards. 

At the expiration of the third week the splint should be removed 
and the elbow gently exercised daily to prevent the occurrence of an- 
chylosis. 

3. Fracture of the Shaft and Lower Extremity of the Ulna. — The 
body of the ulna is most frequently broken at its lower third in an 
28 



434 



PECIAL FRACTURES. 
Fig. 3(53. 



Fig. 364. 




Fracture of the 
shaft of the ulna. 



Apparatus for fracture of the coronoid process. 

oblique direction, as seen in Fig. 364. It is commonly 
caused by a blow or fall upon the ulnar border of the 
forearm.; a fall upon the palm of the hand may also 
produce it. 

Symptoms. — The upper extremity of the bone will be 
held in position by its connections at the elbow, while 
the lower one will be drawn by the pronator quadratus 
outwards, or towards the radius, causing a depression 
upon the ulnar border of the forearm that may be easily 
seen and felt ; crepitus may be elicited by rubbing the ends of the 
bones together in opposite directions. In some cases the displacement 
of the lower fragment deflects the hand to the ulnar side of the axis 
of the forearm. 

Treatment. — If there exist displacement of the fragments, it must 
be corrected by making moderate extension upon the hand, while the 
bones of the forearm are forced asunder by pressure exercised with 
the fingers, otherwise they will become joined together by osseous 
union and the functions of pronation and supination will be destroyed. 

After the bones have been restored to their proper position the limb 
may be put upon a splint, similar in construction to that of Bond, 
with the difference that its lower end must curve in the opposite direc- 
tion, so that the hand may be held in a position of abduction, to throw 
the upper end of the lower fragment away from the radius. 

Fracture of the Carpus. — Fracture of the bones of the wrist is 
always the result of direct and great violence, which commonly lace- 
rates the soft tissues to such a degree as to frequently necessitate 
amputation. 

Treatment. — As there will be much inflammation in these cases, it is 
advisable to simply put the hand upon a broad board in the most con- 
venient posture for the application of the needed dressings, and to 
facilitate the escape of any pus that may happen to accumulate. 

When the inflammatory action has been quelled by appropriate 
remedies, and the soft tissues healed, the wrist should be perseveringly 
exercised to prevent any loss of motion of the joint. 

Fracture of the Metacarpus. — The metacarpal bones suffer most 



FRACTURE OF BOXES OF THE LOWER EXTREMITIES. 435 

frequently from fracture caused by direct violence ; indirect force may 
also cause it, as when a heavy blow is struck with the clenched fist. 

The first and fifth metacarpal bones are more often broken than the 
others. 

From the close connection between these bones no vertical displace- 
ment can take place; the ends of the fragments may be pushed in any 
other direction, though, perhaps, it most frequently occurs backwards. 

Treatment. — The treatment is simple; consisting ■ in the application 
of a wooden or gutta-percha splint to the back of the hand and fore- 
arm, with suitable compresses to correct displacements. 

My experience during the late war in gunshot fractures of both the 
carpus and metacarpus, attended with profuse suppuration, led me to 
prefer an apparatus consisting of a wire frame, applied to the dorsal 
surface of the limb, reaching from a point just below the shoulder to 
the tips of the fingers, and secured to it by broad strips of adhesive 
plaster ; the limb was then suspended in the frame by a cord hanging 
from the ceiling, or from the top of an upright lashed to the bedside. 
This arrangement permitted the easy application of water- dressings, 
or irrigation, and as it allowed the hand to be placed in most any pos- 
ture, it facilitated the escape of pus. 

Fracture of the Phalanges. — Fracture of the phalanges results 
from the same causes that produce this injury in the metacarpus. 

The fragments may be displaced laterally, or be rotated upon their 
axis. 

Treatment. — Redress any displacements of the fragments that may 
exist by making extension and pressure upon the phalanges, and then 
apply a gutta-percha or pasteboard splint, which must be secured with 
a narrow roller, or strips of adhesive plaster. If anchylosis threatens 
to occur, the fingers should be kept in a slightly bent position. 

Fig. 365. 




Splint for fracture of the bones of the fingers. 

A splint sometimes used in treatment of fractured phalanges is seen 
in Fig. 465. 

SECTION IY. 

fracture of the bones of the lower extremities. 

Fracture of the Pelvic Bones. 1. Sacrum. — Fracture of the 
sacrum is caused by direct and great violence applied to the back of 
the pelvis. Its seat is commonly below the sacro-iliac symphysis, and 
its direction transverse. The lower fragment is displaced forwards 
towards the rectum, and in two of the recorded cases of this injury 
compressed that bowel. 



436 SPECIAL FEACTUEES. 

Treatment. — An effort should be made to replace the lower frag- 
ment in its normal position by exercising pressure upon its anterior 
surface with the finger introduced into the rectum. As there is no 
tendency of the fragments to become displaced after the reduction, it 
is only necessary to put the patient into a recumbent posture, and to 
combat local inflammation. 

2. Coccyx. — Fracture of the coccyx results from falls upon the nates, 
and from blows inflicted upon the lower extremity of the spine by 
kicking. The bone is most always displaced inwards. 

Dr. Eoeser records a case {Frorieph Notizen, 1857, Bd. II., No. 10) 
in which the coccyx was displaced laterally. It occurred in a large, 
corpulent woman, thirty-six years of age, who fell from a table upon 
which she was standing astride the back of a low wooden chair. 
Upon examination, a small swelling was felt on the left side of the 
fissure of the buttocks, which proved to be the coccyx torn away 
from the sacrum, and carried towards the descending ramus of the 
left ischium. The reduction was accomplished by making firm 
pressure downwards and to the right against the displaced bone. 

Treatment. — The treatment of this injury is the same as in the 
previous case. 

3. Ilium. — The ilium may be fractured at any point — acetabulum, 
ala, crest, or spinous process. 

The acetabulum may simply have its edge knocked off) or be broken 
into several pieces, which may become so far separated as to permit 
the head of the femur to be shoved into the pelvic cavity. 

This form of injury proceeds from the same causes as does fracture 
of the neck of the femur, though in general the force inflicted will be 
of greater intensity. 

The diagnosis of fracture of the acetabulum, from a similar injury 
of the neck of the thigh-bone, and from iliac dislocation, is often 
quite difficult ; though in the event of a mistake in this respect, little 
harm can result, inasmuch as the same line of treatment is required 
in both varieties of fracture. 

If the edge of the acetabulum is broken away and the head of the 
femur persistently ascends in spite of the extension made upon the 
limb, the retention of the bone in the cotyloid cavity may be rendered 
more secure, by putting a broad belt around the pelvis, having 
fastened to its under surface a padded metallic plate of a semilunar 
shape to press against the trochanter, and thus offer a solid resistance 
to its ascent. 

Should the acetabulum be split in several pieces and the head of 
the femur sunk into the pelvic cavity, the pelvic belt would be useless, 
and extension alone should be depended upon. 

When the superior spinous process is separated from the ala, the 
patient should be placed upon his back and the lower extremities 
flexed and supported on cushions so as to relax the sartorius muscle. 

4. Pubis and Ischium (Fig. 366). — Fractures of the pubis and ischium 
are often associated together, and are always caused by great violence 
applied to the pelvis, as when a person is crushed under a falling 



FRACTURE OF THE FEMUR, 



437 




Fracture of the pubis and ischium. 



wall or between two cars. Fracture Fi S- 366 - 

of the ischium has also resulted from 
falls, from a considerable height, 
upon the nates. 

These accidents are always dan- 
gerous on account of the damage 
done to the viscera of the pelvic 
cavity — rupture of the bladder, ure- 
thra, or rectum. 

Treatment. — The treatment con- 
sists in rectifying displacement of 
the fragments, if any should exist, 
by introducing the finger into the 
rectum ; or, in the female, into the 
vagina, and pressing them into their 
natural position. 

A catheter should be at once 
passed into the bladder and its 
condition ascertained. 

The patient must be put to bed with his body in that position which 
is most comfortable to him ; no apparatus is required except, perhaps, 
when the line of fracture has passed through the symphysis pubis and 
accompanied with a separation of the pubic bones, then, as recom- 
mended by Sir A. Cooper, a pelvic belt may be applied to bring them 
together. 

Perineal abscess, resulting from effused urine, must be promptly 
evacuated by deep incisions. 

Fracture of the Femur. — Fractures of the femur may be divided 
into: 1. Fractures of the upper extremity; 2. Of the shaft; and 3. 
Of lower extremity of the femur. 

1. Fracture of the Upper Extremity of the Femur. — Under this head 
are placed: 1. Fracture of the neck of the femur; and 2. Fracture 
of the trochanter major. 

a. Intra- Capsular Fracture of the Neck of the Femur. — In intra- 
capsular fracture of the neck of the femur the line of fracture, as the 
name implies, passes through the neck of the bone inside of the capsu- 
lar ligament. 

Its position is usually quite near the articulating head of the bone, 
as seen in Fig. 367, though it may occur at any point of the neck; in 
Fig. 368 the fracture is seen at its base. 

The line of fracture is commonly observed to be oblique ; in some 
cases it is transverse. 

Instances have been recorded of incomplete fracture occurring in 
this portion of the bone ; in most cases the fragments are completely 
separated, though rarely they have been found impacted or interlocked 
by the close contact of opposing surfaces presenting corresponding 
indentations and projections. 

If the fragments are free, the muscles will pull the lower fragment 
upwards and backwards, and, in conjunction with the weight of the 



438 



SPECIAL FKACTUKES, 



limb below, rotate it outwards, while the head of the bone remains 
immovable in the acetabulum. 



Fig. 367. 



Fig. 368. 





Fig. 369. 



Intra-capsular fractures. 

Causes. — Intra-capsular fracture is generally caused by some moder- 
ate force acting upon the knee or foot, forcing the femur toward the 
acetabulum, as sometimes occurs in making a 
misstep, or tripping and falling upon the knee. 

It is scarcely ever met with in persons under 
fifty years of age ; beyond this period the bones 
undergo more or less change of structure — the 
cellular substance of the neck of the femur be- 
comes more rarefied and its compact structure 
thinner. In old women, too, the angle formed 
by the neck with the shaft diminishes, and the 
former is thereby less able to resist the influence 
of external forces than it would be if nearer the 
axis of the shaft ; these circumstances strongly 
predispose persons beyond the age mentioned to 
the occurrence of this injury. 

Falls upon the hip will also produce fracture 
of the neck, and cases are related where muscular 
force alone caused it. 

Symptoms. — The external characteristics of 
the fracture are seen in Fig. 369. The patient 
stands upon the uninjured extremity with the 
body inclined forwards ; the fractured limb is 
shortened, the knee and foot strongly everted, 
while the heel is raised from the ground and 
rests in the hollow between the tendo-Achillis 
and the internal malleolus of the ankle of the 

External characteristics of ^ R b rp^ ^ ot wdk ^ 

fracture of the neck of the jrr r . "7 

lemur< the slightest pressure of the loot ot the injured 




FRACTURE OF THE FEMUR. 439 

leg upon the ground causes pain in the hip-joint ; the trochanter major 
will be found nearer the crest of the ilium than its fellow, and at the 
same time is less prominent. 

If the patient be placed in the recumbent posture, the broken limb 
will still be everted by its own weight and the contraction of external 
rotation muscles. 

By the application of moderate force the broken limb may be re- 
stored to its normal length, and during rotative movements crepitus 
will be most always perceptible by placing the ear over the hip ; the 
moment the extending force is withdrawn the limb shortens again. 
During these manipulations preternatural mobility at the seat of injury 
will be marked. 

The shortening will vary from a few lines to an inch and a half, 
according to the damage done to the capsular ligament, and the posi- 
tion of the fragments as regards each other ; for if these are impacted 
or held in approximation by their serrated surfaces, the diminutiou in 
the length of the limb must be inconsiderable; an unruptured capsular 
ligament would scarcely permit more than an inch shortening. 

The decrease in the length of the limb may not be observed to 
follow the injury immediately, but three or four days may elapse 
when by some sudden movement of the patient, turning in bed, for 
instance, the limb will become at once shortened. The most plausible 
reason of this seems to be the slipping of the fragments from each 
other, that have hitherto, by some peculiarity of their surfaces, been 
held in contact. In other instances the limb gradually shortens within 
the first five or six months succeeding the injury. 

The symptoms enumerated above will atteud in almost all cases of 
fracture of the neck of the thigh-bone; in those attended with impac- 
tion crepitus will not be present, unless injudicious movements be 
impressed upon the limb. It has also been recorded that the foot in 
rare instances has been found inverted. 

Prognosis. — Patients recover from this injury in most cases, but as 
the union between the fragments is rarely ever osseous, unless impac- 
tion or an interlocking has occurred, the functions of the limb will be 
more or less impaired; though under the worst circumstances the 
fibro-ligamentous connection that will be established between the 
pieces will be sufficiently firm to enable them to walk tolerabty well. 
In other cases absorption of the fragments occurs to such an extent as 
to render the limb useless. 

Treatment. — The treatment of intra-capsular fracture requires the 
exercise of judgment and discrimination in the selection of the means 
that ought to be employed in the different cases of this injury. 

The indications of treatment are plain, namely, to bring the frag- 
ments into accurate contact, and to retain them in that position until 
the union, of whatever nature that may be, either osseous or ligament- 
ous, occurs. But some of the patients are old, broken down in health, 
and very irritable, who could not bear the necessary confinement and 
restraint a sufficiently long time to obtain so desirable a result. In 
these cases the plan recommended by Sir A. Cooper may be followed, 
which consists in placing the patient in bed with the fractured limb 



440 SPECIAL FRACTUKES. 

supported upon a pillow, and another pillow rolled up and interposed 
between the knees, keep him in this position a fortnight until the 
inflammation about the joint has subsided, then let him rise and sit in 
a high chair ; in the course of time the patient will be enabled to get 
about upon crutches, which, as the convalescence proceeds, may be 
laid aside for a walking stick. 

In other cases, where the health is good and the person not too old, 
efforts should be made by means of suitable apparatus to bring the 
fractured ends of the bone in contact so that when the ligamentous 
union does occur it may be as close as possible. 

To carry out this object those splints should be selected which make 
extension upon the limb, prevent the eversion of the foot, and exert 
some pressure upon the trochanter major. 

In the opinion of Dr. Hamilton, splints constructed upon the prin- 
ciple of Gibson's modification of Hagedorn's apparatus are best calcu- 
lated to procure the desired result. 

The manner of applying this apparatus " consists in extending the 
patient's limbs upon a mattress, and confining both feet, by gaiters, or 
a handkerchief, to a foot-board, which is firmly supported upon the 
ends of two splints passed through mortises near its edges. These 
splints extend from the armpit, where they are padded like the head 
of a crutch, along each of the body, thigh, and leg, beyond the foot, 
and, being well stuffed on their inner surfaces to prevent irritation, 
are confined by six or eight tapes or bandages passed around the 
limbs, pelvis, and chest." (Fig. 370.) 

Fig. 370. 







Gibson's modification of Hagedorn's apparatus. 

"The principle upon which extension and counter-extension are 
effected by this contrivance, will instantly be understood. The sound 
limb being extended, serves as a splint to the broken one. Counter- 
extension then is made upon the acetabulum of the sound side, and 
extension upon the ankle of the injured limb, which, so long as the 
two feet are kept on the same level, cannot be shortened, provided 
rotation of the pelvis be prevented. This purpose is answered by 
extending the splints to the armpits ; and not with a view, as might 
be supposed, of producing counter-extension from these points. Find- 
ing that the patient, in the original machine of Hagedorn, could 
incline the pelvis towards the affected side, and thereby shorten the 
limb, by causing the superior fragment to descend and overlap the 
inferior, the additional splint was added, and has been found to answer 
completely the end designed." 



FRACTURE OF THE FEMUR. * 441 

In my opinion, a much more serviceable and less cumbersome 
apparatus is the one recommended by Prof. Gross. This distinguished 
surgeon states that he employed it for the first time upwards of 
twenty years ago, and has had no reason to abandon its use since in 
the treatment of fractured thigh. The apparatus is so simple, and the 
materials of which it is composed so universally distributed, that the 
surgeon can prepare one in a few minutes wherever he may happen 
to be. It consists of a box made of some light wood, extending from 
the tuberosity of the ischium to the sole of the foot ; its floor is 
grooved, that it may more accurately accommodate the posterior sur- 

Fig. 371. 




Gross's fracture apparatus. 

face of the limb ; the sides of the box are as deep as the anteroposte- 
rior diameter of the thigh, and they are connected by hinges to its 
floor. To the outer surface of the box a movable splint, about two 
inches wide, crutch-shaped at its upper extremity, which is intended 
to reach as far as the axilla, is connected. Another splint, similarly 
constructed, is attached to its inner side, and designed to press against 
the perineum ; an ordinary footboard, with two slits in it, is placed at 
the lower end of the box. 

In applying the apparatus the box should be well padded with 
cotton or tow, or, what is better, wheat bran — especially in compound 
fracture, where there is much discharge. Two long strips of adhesive 
plaster are placed upon the sides of the leg, and secured by a third 
running spirally ; over this the turns of a roller are laid from the foot 
upwards. The limb, having been properly extended, is now put into 
the box, the inner crutch well pressed up against the perineum, and 
the outer one against the axilla ; the extending strips are passed 
through the slits in the footboard and secured to it, after the requisite 
amount of extension has been made. To render the foot more steady, 
it may be further secured to the board by a roller bandage. Lastly, 
a broad splint of leather or binders' board is moulded to the anterior 
surface of the thigh, reaching from the groin to the knee, and secured 
in place by means of pieces of tape encircling the box. 

The principle upon which this apparatus is constructed is evident, 
the counter extension is established at the perineum and axilla, while 
extension is made from the leg by means of the adhesive strips. 

The long splint, known as Liston's, may also be employed in this 
fracture, but extension cannot be made with it with as much force 
and regularity as with the previous splints, and hence it is rather 
adapted to those cases of impacted fracture, in which little or no force 



442 



SPECIAL FRACTURES. 



of the kind is required, but the limb is simply to be held at rest 
while the union is being effected. 

This splint is made of deal-board, or other light wood, of a hand's 
breadth for an adult, but narrower and slighter for a child ; 'it should 
be long enough to reach from a point on a level with the nipple to a 

Fig. 372. 




Liston's splint. 

point three or four inches beyond the foot. On its upper end there 
are two mortises, and at its lower end two deep notches, forming 
three teeth-like projections; at the point corresponding with the ankle 
a hole is to be made to accommodate the external malleolus. 

The splint is to be well padded with cotton-batting, or layers of 
blanket, when it will be ready for use. The injured limb is to be 
prepared by bandaging it from the toes to the groin; and while an 
assistant makes extension from the foot, the straight splint is laid 
upon its outer side; the foot is secured to it by the turns of a roller 
passing around the ankle and across the notches in the lower end of 
the splint, and the bandage is then continued up the limb. The 
counter-extending band is now passed beneath the perineum, and its 
extremities fastened to the holes at the top of the splint. 

An improved form of Liston's splint is recommended by Mr. Haynes 
Walton. As seen in Fig. 373, instead of the two notches at the 

Fig. 373. 




Walton's modification of Liston's splint. 



lower end of the splint, he makes two long slits, by means of which 
the foot can be better secured, by making the purchase from the 

Fig. 374. 




Represents the two slits in Walton's splint. 



FRACTURE OF THE FEMUR, 



443 



ankle, and not upon the heel and dorsum of the foot. This arrange- 
ment also tends to keep the splint square with the leg. 

In the treatment of intra-capsular fracture the double-inclined plane 
has also been employed, and in some instances reported with flattering 
success. 

An apparatus of this sort may readily be extemporized after the 
manner recommended by Dupuytren, which is as follows: Take 
cushions of different sizes and pile them upon one another until the 
double-inclined plane is of the requisite height ; upon this repose the 
limb, and secure it to the plane by two long cravats extending in 
opposite directions across the thigh and ankle beneath the cushions. 

The most perfect contrivance, perhaps, for intra-capsular fracture, 
is the fracture-bed of Dr. Daniels. It permits the limb to be placed 
in a straight or angular position, as the surgeon may require, and can 
be used in fractures of one or both extremities. 

The bed is seen in Fig. 375. A represents a platform of a suitable 



Fig. 375. 




Daniels' fracture-bed. 

length and width, and supported by four legs, a. To the upper sur- 
face of the platform A there is attached a cross-piece, b, at a short 
distance from the centre, and directly through the centre of the plat- 
form there is made a circular hole or aperture, c (in dotted lines), said 
hole or aperture having a semicircular cut or recess in the cross-piece 
b. To the straight edge of the cross-piece b there is attached, by 
hinges, d, a board, B, termed the body plane, the width of which may 
correspond with that of the platform A, and when depressed its outer 
edge may be even with the edge of the platform. The sides of the 
body plane may be elevated, or raised so as to be slightly concave on 
its outer surface. To the opposite side or edge of the cross-piece b, 
and at each side of the semicircular cut or recess formed by the hole 
or aperture c, there are attached by hinges, e, cast-iron plates, O G, 
which are provided with grooves or ways at their sides, in or between 
which plates, D D, work. The plates G C, D D (one on each side) 



444 



SPECIAL FRACTURES. 



are thigh-plates, and their edges are provided with projections, /, 
in which a shaft, g, works, one on each plate 0. On each shaft g 
there is placed a pinion, which gears into a rack attached to the 
under surface of the plates D D. At one end of the shafts g are 
attached ratchets, g', in which pawls, j, catch, said pawls being attached 
to the sides of the plates G C. To the outer edges of the plates 
D D are attached by hinges, k, boards, E E ; these boards are leg 
planes, and are slightly raised at their inner ends, where they are 
connected to the plates D, in order to form depressions to correspond 
to the shape of the legs. To the under surface of each leg plane there 
is attached a metal guide, I, in which a rack, m, works ; the outer ends 
of the racks have bars, n, projecting from them at right angles. To 
each leg plane is attached a shaft, o, having a pinion, p, and ratchet, 
q, thereon, and pawls, r, which catch into the ratchets q, the pawls 
being attached to the outer sides of the leg planes. The pinions 
gear into the racks m. The body plane, and also the thigh and leg 
planes, are covered by a suitable mattress, E, with a hole made 
through it to correspond with the hole in the platform A, and the 
mattress is slit or cut to cover properly the thigh and leg planes with- 
out interfering with their movements. To the under side of the plat- 
form A there is attached by hinges a flap, F, having a stuffed pad or 
cushion, t, upon it, which, when the flap F is secured upwards against 
the platform, fits in the hole in the platform and mattress. The flap 
is secured against the platform by a button, u." 

Fig. 376 represents the bed with a patient upon it, having the ap- 
propriate dressings and splints applied for a fractured thigh. 



Fig. 376. 



..- 




Daniels' fracture-bed with patient upon it. 



b. Extra- Capsular Fracture of the Neck of the Femur. — -This variety 
of fracture is seen in Fig. 377. The injury is outside of the capsule 
and in the direction of the intertrochanteric line. It is commonly 
accompanied with impaction of the upper fragment into the lower, 
and with splitting off of one or both trochanters. 



FRACTURE OF THE FEMUR. 



445 



Causes. — Falls or blows upon the 
hip are the most frequent causes, 
though the fracture may also result 
from counter-stroke — the force being 
applied either to the knee or foot. 

Symptoms. — In the unimpacted 
varieties of this injury, the symp- 
toms will be pretty much the same 
as those observed in intra-capsular 
fracture. If the fragments are held 
together by impaction, of course 
crepitus will not be perceived, nor 
can the leg be restored to its normal 
length by moderate extension. 

The following table, taken from 
Dr. Hamilton's excellent Treatise on 
Fractures and Dislocations, will ex- 
hibit at a glance the chief points of 
difference : — 



Fig. 377. 




Extra-capsular fracture. 



SIGNS OF A FRACTURE WITHIN THE CAPSULE. 

1. Produced by slight violence. 

2. A fall upon the foot or knee, or a trip 
upon the carpet, &c. 

3. Patients generally over fifty years of 
age. 

4. More frequent in females. 

5. Pain, tenderness, and swelling less, 
and deeper. 



(The two following measurements 
to be made from the anterior superior 
spinous process of the ilium to the 
inner condyle of the femur.) 
Shortening at first less than in extra- 
capsular fracture, often not any. 
Shortening after a few days or weeks 
greater than in extra-capsular frac- 
tures ; sometimes this takes place 
suddenly, as when the limb is moved, 
or the patient steps upon it. 



8. Measuring from the top of the tro- 
chanter to the inner condyle, or to 
the malleolus internus, the femur is 
not shortened. 

9. More mobility of limb, at joint. 

10. Trochanter major moves upon a longer 
radius. 

11. If the patient recovers the use of the 
limb, not restored under three or four 
months. 

12. No enlargement or apparent expan- 
sion of the trochanter major, after 
recovery, from deposit of bony callus. 



SIGNS OF A FRACTURE WITHOUT THE CAPSULE. 

1. Produced by greater violence. 

2. A fall upon the trochanter major. 

3. Often under fifty years of age. 

4. Relative frequency in males and fe- 
males not established. 

5. Pain, swelling, and tenderness greater 
and more superficial. It is especially 
painful to press upon and around the 
trochanter. 



6. Shortening at first greater, almost 
always some. 

7. Shortening after a few days or weeks 
less than in intra-capsular fractures. 
That is, the amount of shortening 
changes but little, if at all ; if the 
impaction continues, not at all ; if it 
does not continue, it may shorten 
more. 

8. Measuring from the top of the tro- 
chanter to the inner condyle, or to 
the malleolus internus, the femur 
may be found a little shortened. 

9. Less mobility. 

10. Trochanter major moves upon a 
shorter radius. 

11. If the patient recovers the use of the 
limb, restored in six or eight weeks. 

12. Enlargement or irregular expansion 
of trochanter, which may be felt 
sometimes distinctly through the 
skin and muscles. 



446 



SPECIAL FEACTUEES, 



SIGNS OP A FRACTURE WITHIN THE CAPSULE. 

13. Progressive wasting of the limb for 
many months after recovery. 

14. Excessive halting, accompanied with 
a peculiar motion of the pelvis, such 
as is exhibited in persons who walk 
with an artificial limb. 



SIGNS OF A FRACTURE WITHOUT THE CAPSULE. 

13. The limb preserving its natural 
strength and size. 

14. Slight halt, motions of the hip 
natural. 



Prognosis. — Although osseous consolidation generally occurs after 
extra-capsular fracture, yet this injury should always be considered 
of a grave character, both on account of the damage done to the bone 
itself, and the constitutional disturbance it may involve. 

If splitting of the trochanters complicate the fracture, it will be dif- 
ficult under any treatment to obtain a favorable result, as far as the 
utility of the limb is concerned. Impacted fractures are less serious 
than those not so. 

Treatment. — The treatment of extra-capsular fracture may be con- 
ducted with the apparatus already described, or with the contrivance 
of Prof. Miller, which consists of a straight light wooden splint (Fig. 
378). " It should extend from a little below the axilla, to a little be- 

Fig. 378. 




Miller's splint for fracture of neck of femur. 

yond the ankle, when the patient is straight and recumbent; and, 
having been well padded, more especially at the points where pressure 
is likely to be greatest — at the trochanter, external condyle, and mal- 
leolus, or by the swathing of a broad linen sheet. Then a soft shawl, 
or other suitable band is pressed beneath the perineum, on the affected 
side ; and has both its ends tied on the upper end of the splint, there 
being two holes placed there for this purpose." 

Fig. 379. 




Miller's splint applied. 



" A broad bandage or belt is also applied firmly round the pelvis, 
so as to bind the splint more securely on the limb, and keep the broken 
surfaces in apposition. By tightening the perineal band, from time to 



FRACTURE OF THE FEMUR. 



447 



time, the splint is forced downwards ; the splint, having been made of 
a piece with the limb, brings the latter with it." 

c. Fracture of the Neck of the Femur, partly Extra- Capsular and 
partly Intra- Capsular . — This variety of fracture of the neck of the 
femur results from the same causes that produce extra-capsular frac- 
ture. 

Union by bone takes place between the fragments. 

This fracture will be characterized by the same set of symptoms 
that we have already described under the head of intra-capsular frac- 
ture ; and will require in its treatment the apparatus we have just now 
considered. 

d. Fracture of the Trochanter Major. — Fracture of the larger tro- 
chanter is commonly found as a complication of extra-capsular fracture, 
yet in rare cases it has been detached from the shaft of the femur 
without any other injury to the bone, the line of separation running 
downwards and outwards. 

In young subjects an epiphyseal separation has also been recorded. 

The trochanter is not generally displaced, in consequence of some 
of the soft tissues connecting it with the shaft remaining untorn. 

Causes. — It may occur at any age, though in the cases reported it 
has taken place in old persons from a blow upon the hip. 

Symptoms. — The limb is perfectly helpless, and lies in an everted 
position ; by measurement it will be found of the same length as the 
opposite one. When the thigh is rotated the trochanter does not par- 
ticipate in the motions of the femur. If displacement occurs, it will 
be either upwards or backwards, generally the former ; if the limb be 
abducted and the trochanter brought down, the broken surfaces may 
be pressed in contact, and crepitus developed by rubbing them 
together; should the patient be in the erect posture, he cannot sit down, 
from the extreme pain which efforts to do so cause him. 

Treatment. — Sir A. Cooper recommends the apparatus sketched in 
the annexed wood-cut, in the treatment of this injury. He places the 

Fig. 380. 




Sir A. Cooper's apparatus for the fracture of the trochanter major. 

patient upon a firm mattress, provided with an arrangement for using 
the bed-pan ; at its lower end an upright support is attached, to which 
the foot is secured. A broad belt is made to encircle the pelvis, so as 
to sustain the trochanter in its normal position. To hold the leg im- 
movable, after the application of the pelvic belt two lateral splints 
may be applied. 



448 



SPECIAL FRACTURES. 



Fig. 381. 



The apparatus should be continued for a month, when the patient 
may be permitted to get up and move around. 

In most cases union by bone has taken place promptly without any 
danger being inflicted upon the functions of the hip-joint. 

2. Fracture of the Shaft of the Femur. — Fracture of the shaft of the 
femur may occur at any point in its length, but is most frequent in its 
middle third. The character of the fracture is various, it may be sim- 
ple or comminuted, compound or complicated with other injuries. 

Its direction is commonly oblique, though 
when it takes place at the base of the con- 
dyle, or in young subjects it is often transverse. 
The displacements that follow depend upon 
the position of the fracture ; if this is towards 
the upper end, the psoas magnus and ilia- 
cus internus will tilt the upper fragment 
forwards, while the large adductors upon the 
inner side of the thigh will draw the lower 
fragment upwards and inwards, behind the 
upper, and at the same time will rotate it 
outwards. 

In fracture seated about the middle of the 
femur the lower fragment will be displaced 
as in the former case, but the upper one will 
rather be drawn a little outwards, and ride 
over the lower. 

Transverse fracture just above the con- 
dyles, from the breadth of the opposing sur- 
faces may not be attended with any displace- 
ment, but if it is oblique, the lower fragment 
will be drawn backwards and downwards by the gastrocnemius, plan- 
taris, and popliteus. 

Symptoms. — There is usually shortening to a considerable extent ; 
preternatural mobility at the point of fracture when the limb is lifted 
from the bed ; the patient cannot move the leg ; the foot is everted ; 
and crepitus will be developed by rubbing the fragments against each 
other. 

Prognosis. — Fracture of the shaft of the femur is always a serious 
injury, and when the line of division is oblique, it is almost impossible 
by any apparatus to procure a cure without some shortening. 

Treatment. — In the treatment of this injury it is of great importance 
to procure a suitable mattress upon which to place the patient during 
the period of his confinement. If it is possible to obtain one, a frac- 
ture-bed should be chosen in which provision is made for all the re- 
quirements of the case. 

We have already described the fracture-bed of Dr. Daniels. It 
offers many advantages in conducting the treatment of fracture of the 
femur ; there are others also equally as efficient, and require a passing 
notice. The fracture-bed invented by Mr. Jenks, of Providence, Ehode 
Island, will be found ingenious and useful. " It is composed of two 
upright posts about six feet high, supported each by a pedestal — of 




Fracture of the base of the 
condyle. 



FRACTURE OF THE FEMUR 



449 



two horizontal bars, at the top, somewhat longer than a common bed- 
stead — of a windlass of the same length placed six inches below the 

Fig. 382. 




Jenks' fracture-bed. 

upper bar — of a cogwheel and handle — of linen belts, from six to 
twelve inches wide — of straps secured at one end of the windlass, and 
at the other having hooks attached to corresponding eyes in linen 
belts, from six to twelve inches wide — of straps secured at one end of 
the windlass, and at the other having hooks attached to corresponding 
eyes in the linen belts — of a head-piece made of netting — of a piece of 
sheet-iron twelve inches long, and to fit and surround the thigh — of a 
bed-pan, box, and cushion to support it, and of some other minor 
parts. The patient, lying on his mattress, and his limb surrounded 
by the apparatus, the surgeon, or any common attendant, will only 
find it requisite to pass the linen belts beneath his body (attaching 
them to the hooks at the ends of the straps, and adjusting the whole 
at the proper distance and length, so as to balance the body exactly), 
and raise it from the mattress by turning the handle of the windlass. 
While the patient is thus suspended, the bed can be made up, and the 
feces and urine evacuated. To lower the patient again and replace 
him on the mattress, the windlass must be reversed. The linen belts 
may then be removed, and the body brought in contact with the 
sheet." 

A much less expensive contrivance than Jenks' fracture-bed is an 
arrangement devised by Dr. A. Hewson, and described by him in the 
Am. Journ. Med. Sci., for July, 1858. It has also the great advantage 
of being easily connected with an ordinary bedstead. As seen in the 
figure, a board (A B, Fig. 383) fifteen or eighteen inches broad, and 
of sufficient length, is to be substituted for three or four of the slats 
29 



450 



SPECIAL FRACTUKES, 



forming the bottom of the bedstead. The ends of this board (A and B) 
should be cut so as to fit in the mortises originally made in the sides 
of the bedstead for the slats, In the centre of this board there should 

Fig. 383. 




Hewson's fracture-bed. 



be an oval hole (<7) ten by seven inches, its long diameter correspond- 
ing to the length of the bedstead. To the upper and lower borders 
of this board there should be secured strips, D E and F G, extending 
between the sides of the bedstead. These strips should have grooves 
near their lower borders, and running their full length, as seen on F G, 
for the tray containing the bedpan to slide in. They (the strips) should 
have a depth sufficient to make the plane of these grooves below the 
plane of the sides of the bedstead. To the bottom of the board (sub- 
stituted for the slats) there is to be hinged a trap-door, H, to which an 
oval and somewhat conical pad is to be secured. This door should 
have a length equal to a little over one-fourth the width of the bed- 
stead, and a breadth of twelve inches. It may be made of one inch 
stuff; and should then have secured, at equal distances on its under 
surface, two or three strips an inch broad, and with a depth sufficient 



FKACTURE OF THE FEMUR, 



451 



to bring their lower surface (when the door is shut up) on a level with 
the upper edge of the grooves in the side-pieces, on the upper surface 
of the tray. These strips should terminate in a cross-piece at the far 
end of the door, and this last piece should extend an inch on either side 
beyond the door. 

A tray (Fig. 384) of sufficient width to slide in the grooves of D E 
and F G, Fig. 383, should be made of one inch stuff, and have a length 
equal to five-eighths the width of the bedstead. This tray should have 
in it an oval hole ten by seven inches for the pan, and a square hole 

Fig. 384. 




fully equal in length and breadth to the door, save at the end near 
the hole for the pan ; here this square opening should be increased in 
width by the removal from either corner of a piece one inch by two 
and a half inches, so as to allow the jutting ends of the cross-piece 
attached to the door to fall through as the pan is pushed towards the 
hole in the bed, or to rise up above the tray when it is desired to re- 
move the pan and replace the plug. To close up the door, and thus 
replace the plug in the mattress, without any friction or jarring, a 
wooden roller of two and a half inches diameter should be secured to 
the under surface of the tray at the far end of the square opening, and 
at such a distance from the notches for the escape of the cross-piece of 
the trap-door as will be equal to two-thirds the length of the door. 
The tray is to be moved by a handle attached to it by a pivot. 

For the purpose of preventing the attendant from pushing or pull- 
ing the tray too far in either direction, stops should be provided, such 
as are indicated at D E and F G. Thus at D E there is a strip ex- 
tending between the cleats which will check the tray in that direction 
by the roller striking against it. Then the tray cannot be drawn out 
too far by the two little points on the bottom of the tray, at / and K, 
infringing on the stops indicated at E and C. 

These last checks allow of the tray being drawn out sufficiently far 
from beneath the bed for the removal of the pan, and when the tray 
is drawn out this far, the trap-door is supported up in its place by the 
jutting ends of the cross-piece resting on the distant end of the tray. 
These jutting ends continue to support the door as the tray is pushed 
in, until it is pushed so far as to bring the notches in the square 
opening beneath these ends, when all support is removed from the 
door, and it falls rapidly by its own weight; then, by continuing to 



452 SPECIAL FRACTURES. 

push the tray inwards, the pan is brought beneath the opening in 
the bed. 

A hole should be made in the mattress to correspond with that in 
the board. It should be oval, and measure ten by six inches on the 
upper surface.- The far side of this hole (from the hinges of the door) 
should be bevelled, so that it will measure in the lower surface ten by 
seven inches. To prevent the weight of the patient pressing the mat- 
tress over into this opening, the edge of the hole in the board should 
be bound round with tin, jutting an inch and a half above its upper 
surface. 

The apparatus will work best when the hinges of the door are as 
far as possible from the hole, and the plug placed as near as it can be 
to the free end of the door. The plug will thus be made to describe 
the arc of the largest circle possible in the swinging of the door, and 
will therefore not require to be bevelled as much as it would if placed 
in the centre of the door, and the door hinged nearer to the opening. 
The bevelling of the plug and of the hole in the mattress is only 
required on one side — the side towards the handle of the tray — and if 
this bevelling is made to correspond with the arc of the circle de- 
scribed by the upper and far edge of the plug, the plug will fit with 
great accuracy in the opening. This plug should be secured firmly 
to the door, either by being tacked to it or fastened by tapes passed 
through holes provided for the purpose. 

When these more convenient and perfect apparatus are not attain- 
able, the surgeon can extemporize a simple arrangement, by means of 
which the patient's position need not be disturbed in using the bed- 
pan or changing the bedclothes. It is thus prepared: Upon the mat- 
tress intended to be lain on by the patient, a piece of stout canvas is 
spread, and kept stretched by being nailed or sewed to an ordinary 
cot frame. In its centre, corresponding to the nates, a hole is cut. 
Two sheets are doubled and placed over the canvas, with their folded 
margins meeting at the hole. The sheets and frame should lie 
smoothly upon the mattress, that no inequalities be presented beneath 
the patient to hurt his skin. When it is necessary to use the bed- 
pan, all that is necessary is to raise the patient from the mattress with 
the cot frame, and support it by four blocks placed under its corners; 
or, what I always use, a rope attached to the two ends of the frame, 
and running over the cross-pieces of the bedposts. The pan may then 
be shoved beneath him, the folded edges of the sheets having been 
previously turned aside. 

When the surgeon has selected and prepared his bed, he is then 
to apply his splints, of which there are a great variety employed in 
the treatment of fracture of the shaft of the femur. Some surgeons 
employ, in all cases, splints that maintain the limb in an angular 
position; others, those that keep it straight; while a third class use 
both kinds — the angular, in fractures of the upper and lower ends of 
the femur, and straight splints in fracture of its middle portion. 

Mr. Pott was the first to bring into notice, and cause to be adopted, 
the treatment of fracture of the thigh with the limb -in a bent posture. 
His object was to relax those muscles which he believed to be the 



FKACTUKE OF THE FEMUR. 453 

principal agents in deranging the fragments by their contraction. 
The fact did not seem to occur to Mr. Pott that, in thus relaxing one 
set of muscles, he must necessarily put those opposing them in a pro- 
portional degree of extension. However, the principal objections to 
Pott's plan are, that the limb is not properly secured, and therefore is 
constantly liable to be disturbed, and the fragments displaced; and 
that the weight of the body is sustained upon the trochanter of the 
injured side for too prolonged a period to escape injury. I have 
employed the method with advantage in certain cases of gunshot 
fracture, with laceration of the soft tissues. 

Mr. Pott directs that " the position of the fractured os femoris should 
be on its outside, resting on the great trochanter ; the patient's whole 
body should be inclined to the same side ; the knee should be in a 
middle state, between perfect flexion and extension, or half bent ; the 
foot and leg lying on their outside also, should be well supported by 
smooth pillows, and should be rather higher in their level than the 
thigh ; one very broad splint of deal, hollowed out, and well covered 
with wool, rag, or tow, should be placed under the thigh, from above 
the trochanter, quite below the knee ; and another, somewhat shorter, 
should extend from the groin below the knee on the inside, or rather 
in this posture on the upper side ; the bandage should be of the 
eighteen-tail kind ; and when the bone has been set. and the thigh 
well placed on the pillow, it should not, without necessity (which 
necessity in this method will seldom occur), be ever moved from it 
again until the fracture is united; and this union will always be 
accomplished in more or less time in proportion as the limb shall 
have been more or less disturbed." 

To obviate the objections to Pott's plan Sir C. Bell recommended a 
modification of the bent posture, the peculiarity of his method con- 
sisting in supporting the limb upon a double-inclined plane, the patient 
lying upon his back. The plane was constructed of two boards ten 
or eleven inches wide, joined together at such an angle under the 
popliteal space that the hip and knee-joints should be slightly bent. 
A cushion was laid over the frame, and in order to give support and 
steadiness to the limb and prevent the lateral inclination of the foot, 
a number of holes were bored in the margins of the boards to receive 
wooden pins, which held the sides of the cushion against the leg. 
When the fracture was reduced and the limb placed upon this appa- 
ratus, two splints were secured to the sides of the thigh by an eighteen- 
tail bandage. 

Many modifications of this apparatus of Bell have been employed 
since. The one seen in Fig. 385 was used at the Middlesex Hospital, 
London, according to Mr. Lonsdale, in 1838. 

It differs from the preceding one in having a horizontal board 
attached by one extremity to the upper end of the thigh-plate, while 
the other extremity of the board supported the lower end of the leg- 
plate upon a number of notches, which enabled the surgeon to vary 
the angle according to his pleasure. The thigh-piece, which is hinged 
to the leg-plate, consists of two pieces instead of one, so that it may 
be adapted to limbs of different lengths. 



454 



SPECIAL FEACTURES. 






In applying the apparatus it is recommended to pad it with flannel 
so as to make a smooth and uniform bed upon which to lay the limb, 

Fig. 385. 




Double-inclined plane. 



and then to secure to the front and sides of the thigh three splints with 
an eighteen-tail bandage. The foot is fastened to an upright support 
by the turn of a roller, which is to be continued upwards ; to finish, the 
pegs are inserted into the holes along the sides of the boards. Fig. 




The same applied. 

386 shows the apparatus applied; the lines A and B indicate the proper 
positions that the angle of the frame and the upper end of the hori- 
zontal board should occupy. 

In using the double-inclined plane, the weight of the body is made 
to serve the purpose of a counter-extending force, and thus drawing 
upon the foot attached to the upright support establishes the extension, 
which certainly cannot thus be accomplished with any uniformity or to 
any great extent. From the fact of the pelvis not being in any manner 
connected with or controlled by the apparatus, it is at liberty to move 
in any direction, and will displace the upper fragment. In employing 
the apparatus, it will be found necessary to attempt to obviate this 
obstacle, and also to prevent the loss of contiguity of the two frag- 
ments by lateral deflection of the upper one, by shifting the position 
of the double-inclined plane, bringing it towards or removing it from 
the sound limb, according to circumstances. 

Mr. Amesbury endeavored to fix the pelvis by the apparatus seen 



FRACTURE OF THE FEMUR, 



455 



in Fig. 387. It consists of three portions, one (a) for the thigh, 
another (b) for the leg, and a third (c) for the foot. To each apparatus 

Fig. 387. 




Amesbury's double-inclined plane. 

there are two thigh-pieces, one bevelled to the right at the lower end, 
and the other to the left, one or the other being used in connection 
with the leg-piece, according as the apparatus is to be applied to the 
right or left extremity — for the reason that a perfectly formed limb is 
not straight, but turns inwards at the knee. The thigh and leg por- 
tions are connected together by a joint, which is controlled by a steel 
rod (e) attached by one end to the back of the leg-piece, and at the 
other moves in a rack placed upon the posterior surface of the thigh- 
piece, to which it can be secured at different points with a little pin ; 
this arrangement allows the angle of the plane to be varied at pleasure. 
To the upper part of the thigh-piece there is a sliding plate which 
permits this piece to be adapted to limbs of different lengths ; the 
plate itself is turned off at its upper edge so that, when properly 
padded, it may press against the tuberosity of the ischium without 
damaging the skin ; it also has soldered to its back two bars, under 
which the pelvic strap passes. The pelvic strap is made of leather 
with a sliding pad upon it. 

In the application of the apparatus it should be first well padded 
(Fig. 388) ; a roller bandage is then placed upon the leg from the 

Fig. 388. 




The same applied. 

toes to the knee, and the limb placed upon the plane ; the foot is in- 
closed in the shoe (a), supported by the footboard, nearly at right 
angles with the leg-piece ; inequalities beneath the limb are corrected 
by stuffing between it and the splint cotton or tow. The leg is 
secured to the apparatus by the turns of a roller bandage reaching 
from the ankle to the knee. An assistant now makes extension by 



456 SPECIAL FRACTUEES. 

seizing the knee while the surgeon coaptates the fragments and then 
applies the splint, the first to the outer side of the limb, the second 
upon its inner side, and the third upon the front part of the thigh ; 
the splints are held in place by the straps. The pelvic strap is now 
carried around the thigh, and made to cross on the outer side, while 
the buckle-end, with the sliding pad, is carried around the pelvis and 
made to meet the other end in front, where they are fastened together. 
The lower part of the apparatus is fixed to the foot of the bed by the 
tapes. 

Dr. J. C. Nott has also devised a double-inclined plane, which differs 
very little from the one described by Mr. Lonsdale. The tuberosity 

Fig. 389. 




Nott's double-inclined plane. 

of the ischium rests upon the upper end of the thigh-piece; the thigh 
has two splints upon its sides, secured by buckles and straps, and so 
has the leg; the horizontal board consists of a single piece notched at 
its far end. 

The inclined plane is also used by surgeons in the treatment of 
fractured thigh, suspended from the ceiling, or the top of the bed- 
stead. It maintains the leg in the flexed position, and at the same 
time allows it to move laterally, or to participate with the trunk in 
any of its movements. The suspension plan is of real service, and I 
know of nothing superior to it in certain cases of compound fracture 
of the thigh, with laceration of the soft parts ; and during the late war 
the anterior splint of Prof. N. E. Smith, of Baltimore, was deservedly 
held in high esteem by military surgeons in such cases. 

Mayor's apparatus for fractured thigh consists of a wire frame, with 
a thigh and leg-piece fastened together at an angle which may be 
varied by the tension of a chain passing from the cross-bar at the 
upper end of the frame to the top of the bent section of the leg-piece, 
which is made to answer the purpose of a foot-board. 

Upon this frame a cushion is placed, on which the limb is laid and 
secured by three cravats passing around the thigh, leg, and foot. A 
fourth cravat encircles the hips and upper part of the thigh, having 
its ends attached to the thigh-piece upon both sides; this secures the 
apparatus to the pelvis. The frame is now slung, by means of cords 
connected with the upper and lower corners of the leg section, from 
the ceiling or top of the bedstead. 



FRACTURE OF THE FEMUR, 



457 



The double-inclined plane of Prof. Smith (Fig. 390) is slung with 
cords in the same manner, but the apparatus is constructed with two 

Fig. 390. 




N. K. Smith's double-inclined plane. 

lateral iron bars, jointed at their middle, and extending from the hip 
to the foot. The upper sections of these bars, corresponding with the 
thigh, are joined together by a metallic trough ; the leg is supported 
by broad bands of webbing, passing between the bars of the lower sec- 
tions, to the far end of which a footboard is attached. At the top of 
the outer bar a curved metal stem is placed bearing the pelvic strap. 

In applying this apparatus, it is first to be padded with flannel 
or cotton-batting. The limb is now raised and extended by an as- 
sistant, while the surgeon places the frame beneath it and secures the 
foot to its board by a roller bandage; the leg-bands are fastened, 
and a broad splint, laid upon the anterior surface of the thigh, is 
secured by straps. The pelvic strap is passed round the hips, and 
buckled ; and lastly, the apparatus is suspended by a cord from the 
ceiling. 

The "anterior splint" of the same distinguished surgeon is formed 
of wood or wire, the latter being preferable. It is intended to be 
applied to the anterior plane of the limb, and slung from the ceiling. 

Fig. 391. 




N. R. Smith's anterior splint. 

The wire splint (Fig. 391) may be prepared by the surgeon in a few 
minutes, whenever wire is attainable, of which ISTos. 8 or 9 will answer 
the purpose; of this a piece is taken of sufficient length, when doubled 
and bent to the limb, to reach from the anterior-superior spinous pro- 
cess to a point two inches beyond the toes. The two sides of this are 
now expanded so as to be as broad as the limb; that is, wide above, 
and gradually tapering to the toes. To retain this form, cross-pieces 
of a smaller sized wire are connected with them; two of these cross 



458 



SPECIAL FRACTURES 



wires, one over the thigh and the other over the leg, have an eye 
worked in at their centres for the attachment of the suspending cord. 

The wire frame thus prepared is bent at the groin, knee, and ankle, 
so as to lie in exact contact with the anterior plane of the limb, which 
is to be slightly flexed. 

The splint is now enveloped in a layer of cotton batting, and encir- 
cled with a roller bandage and laid upon the limb. Three or four 
strips of adhesive plaster are applied round both splint and limb, at 
the sole of the foot, middle of leg, and thigh. These will support the 
parts, while the surgeon applies a roller bandage from the toes upwards. 
Arriving at the pelvis, a spica of the hip should be formed with the 
roller. When this is finished, the apparatus is to be slung from the 
ceiling by a cord, to which a certain degree of obliquity is to be given. 
(Fig. 392.) 

Fig. 392. 




The same applied. 

The obliquity of the cord, and the application of the splint upon the 
anterior surface of the limb, are the peculiarities of Dr. Smith's appa- 
ratus. It is by the first that extension is made, which will, of course, 
vary in intensity with the degree of this obliquity. The cord, in this 
position, is constantly pulling the patient towards the foot of the bed, 
while the only resistance offered is by the weight of the body, which 
forms, therefore, the counter-extending force. 

In compound fractures, resulting from gunshot, attended with lace- 
ration of the soft parts, I have employed this splint a number of 
times with the most decided advantage, and I think, under such cir- 
cumstances, it has given more relief to the patient than any other con- 
trivance I am acquainted with could have done. It facilitates the 
dressing and cleansing of the parts, does away with the constant dis- 
turbance of the limb for these purposes, and supports it in such a 
manner that it may be moved about with facility in a horizontal plane, 
permitting also the position of the patient to be changed without dis- 
turbing the limb. 



FRACTURE OF THE FEMUR 



459 



Dr. James Palmer, U. S. X., has modified the "anterior splint" for 
double fracture, as seen in Fig. 393, and described in the Amer. Journ. 
Med. Sciences, Xo. 99, for 1S65. It consists of two continuous parallel 
rods of R~o. 9 iron wire, passing over the anterior surfaces of both 
limbs from the toes upwards, arching over the pubes clear of the ante- 
rior spinous processes, and bent at the groins at an angle of about 
thirty degrees. The abdominal arch was well padded, and the whole 
apparatus, enveloped with roller bandages, as usual, was first secured 
to the pelvis, a trough of binders boards beiDg accurately moulded 
to the back of each thigh ; bandages from the toes upwards were next 
applied around each limb, including the splint, and when they reached 
the groins were secured to the arch on each side, and the ends, finally 
carried over the mattress, clear of the patient's body, were made fast 
to the head of the iron bedstead, the weight of the body making the 
counter-extension. Lastly, the limbs, separately slung, w r ere suspended 
by a single cord passing over a pulley at the ceiling, and making 
extension at an angle of about thirty degrees, as seen in Fig. 393. 



Fig. 393. 




Palmer's modification of the anterior splint. 



Dr. Palmer suggests an improvement upon this by bending the wires 
outwards and downwards at the instep, and carrying them out parallel 



460 SPECIAL FKACTUKES. 

with the soles of the feet, so as to secure to their ends a copper trough, 
to which the patient's own shoes may be attached for support at the 
heels. 

Although there are certain cases in which it would be advisable 
to treat fracture of the thigh in the bent position, yet as a general 
method the straight position should be preferred. We have already 
indicated above the instances in which this preference should be exer- 
cised, viz., fractures just below the trochanter minor, in which the 
upper fragment is tilted upwards and somewhat outwards, and at the 
base of the condyles, the inferior fragment being acted upon by the 
muscles of the calf of the leg, and drawn backwards. In the first in- 
stance, by bending the thigh upon the pelvis, the psoas magnus and 
iliacus are relaxed, and the fragment into which they are inserted 
permitted to descend in line with the axis of the rest of the bone ; 
and in the second, the flexion of the knee relaxes the muscles of the 
calf, which displace the lower fragment backwards. 

This method of treatment was particularly recommended by De- 
sault, and is generally adopted by American surgeons. The parts of 
this surgeon's apparatus are : 1st. Three splints, each one and a half 
inch wide, a long one to extend from the crest of the ilium to a point 
four inches beyond the foot, intended for the external surface of the 
limb ; its ends are concave, and mortised ; a second splint, somewhat 
shorter, for the inner surface of the limb, extending from the perineum 
to the sole of the foot ; a third short splint, reaching from the fold of 
the groin to the knee. 2d. Three cushions filled with bran or oat 
chaff. 3d. A bandage of Scultetus, the strips of which are long 
enough to reach twice around the limb, overlapping each other about 
one-third of their breadth, and variable as to number, ascending to the 
requirements of the case. 4th. Two oblong compresses. 5th. Two 
strong strips of bandage for extension and counter-extension. 6th. 
A splint-cloth and body bandage. 

The apparatus is applied by spreading upon the bed the splint-cloth, 
which may be a piece of stout muslin, two yards long and as wide as 
the inner splint; upon this the bandage of Scultetus is placed, reach- 
ing from the ankle to the hip. The limb having been laid on the 
centre of the bandage, extension is made from the leg, and the sur- 
geon, having coaptated the fragment, puts one of the oblong compresses 
along the anterior surface of the thigh, and then applies the bandage 
of Scultetus ; the ankle is padded with tow, or inclosed in a compress, 
and the extending band is applied ; the three cushions are next put in 
position, and the lateral splints rolled up in the splint-cloth from its 
edges against the limb, so as to compress it uniformly ; the third splint 
is placed on the thigh. Five strong bands are now fastened around 
the limb to secure the apparatus. The extending and counter-extend- 
ing bands are passed through the mortises, and tied over the ends of 
the long splint; the upper extremity of this splint is bound to the 
side of the pelvis by a broad bandage. Any tendency to lateral devia- 
tion of the foot is prevented by passing a strip of bandage about it, 
and pinning it by its ends to the splint-cloth. 

The objection to the apparatus of Desault is, that the extending and 



a a 



FRACTURE OF THE FEMUR. 461 

counter-extending forces do not act in the line of the axis of the 
broken limb, but obliquely, so that the perineal band is constantly 
disposed to draw the upper fragment outwards. 

To obviate this Dr. Physick modified Desault's long splint by ex- 
tending it up to the axilla, so as to bring the line of traction of the 
perineal band in the direction of the axis of the broken leg ; „. 394 
he also observed that the extending band drawing with much 
force pulled the foot against the lower end of the splint and 
bent the ankle, and suggested to Dr. Hutchinson to have re- 
course to some expedient to correct the oblique traction; the 
latter gentleman then adopted the notched block nailed to 
the lower end of the splint, as seen in Fig. 394. This splint 
is otherwise like that of Desault's, and is applied in the same 
manner. 

The next apparatus that has enjoyed the confidence of 
many of the continental surgeons is that of Boyer. It 
consists of an external long splint (Fig. 395), reaching from 

Fig. 395. 




Boyer's apparatus. 

the hip to beyond the sole of the foot; its upper end is 
attached to the outer side of the counter-extending band, 
while the lower one is peculiarly constructed, by having a 
fenestrum cut into it, through which a long screw moves by 
a crank. The screw supports a plate to which the foot- 
board is attached, and confers upon the latter a certain 
range of vertical motion. There are two other splints for 
the inner and anterior surfaces of limb. The lower end of 
the apparatus is supported upon the mattress by two pro- 
jecting stems attached to the footboard. 

The splints are cushioned and applied in the same manner 
as the apparatus of Desault, already mentioned. 

The peculiarity of Boyer's splint consists in the manner 
of making extension by fastening the foot to an upright p hysick's 

J l_ splint. 

support moved by a screw. 

An apparatus constructed by Dr. Alonzo Chapin is seen in Fig. 396. 
The long splint (1) has four holes at its upper extremity, and three 
tenons at its lower, the latter corresponding with an equal number of 
tenons in the distal end of the inside splint are intended to support a 
transverse bar. Through the bar two holes are pierced for two hooked 
screws to work in ; the screws are moved by nuts abutting against 
the outer side of the bar, and when the splint is applied the extending 
bands are hooked to the screws. The inside splint is concave at its 
proximal end and perforated with two holes through which the 



462 



SPECIAL FKACTURES. 






counter-extending band passes and presses the splint against the 
perineum. The apparatus is applied in the usual manner to the limb 

Fig. 396. 



o o 
© o 



DDDl 



■i 



ODD 



♦I 



Chapin's apparatus. 

protected with cushions. Should occasion require, the splints may be 
drawn asunder and the limb examined without disturbing it. 

This peculiarity of the counter-extending band, acting upon the 
perineum by pressing the upper end of the inside splint against it, is 
also seen in the apparatus (Fig. 397) of Prof. W. E. Horner, which 

Fig. 397. 




Horner's apparatus. 

has, besides, the cushions immovably fixed to their inner surfaces. 
The end of the splint is notched, and spanned with a leathern strap, 
while the perineal band is attached below by passing under two 
leathern loops. 

Dr. Joseph B. Hartshorne does away with the perineal band for 
counter-extension altogether, and in his apparatus, shown in the 
annexed drawing (Fig. 398), pads the upper end of the inside splint 

Fig. 398. 




Hartshorne's apparatus. 

to press against the perineum and make counter-extension. The two 
splints are connected below by two cross-pieces supporting a wooden 
screw, which moves the footboard. The splints may be separated 
from each other, and the long splint removed if the necessities of the 
case should demand. 



FRACTURE OF THE FEMUR, 



463 



Drs. Burges have constructed an ingenious fracture apparatus, 
sketched in the following drawings (Figs. 399, 400), in which, to ob- 



Fiff. 399 




Burges' apparatus. 

Fie. 400. 




The same applied. 

viate the injurious effects of pressure of the counter-extending band 
upon the perineum, they have transferred the resistance, in a measure, 
to the tuberosity of the ischium. 

The apparatus consists of: "A, thick mattress. B, thin mattress. 
C. wooden platform upon which the thin mattress is laid. This plat- 
form is made in two pieces, aud hinged together so as to fold upon 
itself for convenience of transportation, and when in use is merely 
hooked upon the central platform D. 

"D, central or cushioned platform supported at either end by wooden 
strips marked E, which rest upon F, a second platform of same 
extent as D. This constitutes a shelf for the bed-pan, which may be 
introduced below from either side. 

" G, hair cushion, upon which the hips of the patient rest. This 
cushion, as well as the platform D, to which it is buttoned, has a 
semicircular opening at its lower margin for convenience of defecation. 

"H, a rectangular wooden slide, exactly corresponding to its fellow 
upon the opposite side of the pelvis. These slides are so arranged 
upon the platform D as to be separated or approximated at will, and, 
by a thumb-screw which passes through a fissure in the horizontal 
portion of each, they may be fixed at the desired point so as exactly 



464 



SPECIAL FRACTURES. 



Fig. 401. 



to embrace the pelvis of any patient. There is also a fissure in the 
perpendicular position of each rectangular slide, and a screw passing 
through the same. One of these is to secure the upper end of the long 
splint J, and the other for the attachment of a short splint /, upon 
the side of the pelvis, corresponding to the uninjured limb. Both 
of these splints are well padded upon one surface, and may be elevated 
or depressed at will, in order to bring them to the level of the limb 
and fixed at the proper altitude by the screws already mentioned. 
They are also mutually transferable, thus adapting the apparatus to 
fractures of either thigh. 

"SS, counter-extending pads. These are attached by leather straps 
to the upper surface of the platform D, about twelve inches apart. 
Passing under the cushion G, and becoming well-rounded 
pads, they traverse the tuberosities of the ischia, pass 
between the thighs, and thence perpendicularly to the 
horizontal iron rod or crossbar L. The crossbar L is 
supported at each end by a perpendicular bar extending 
upwards from the platform D. Attached by one ex- 
tremity to the crossbar L is a rod P, running parallel 
with and situated directly above the thigh. The other 
end of this rod P is supported by an arched iron bar 
N, extending upwards from the outer side of the long 
splint J. The rod P is designed to afford special sup- 
port to the injured limb whenever such support is 
deemed advisable. Two or three strips of cotton cloth, of 
suitable width, may be passed around the limb, either in- 
ternally or externally to the splints of coaptation, and 
tied over the supporting rod P. Splints of coaptation 
are to be applied according to the exigencies of the 
case. 

" M, an inside splint covered by the bandages. Q, the 
screw by which extension is effected in the ordinary 
way, having at an extremity a swivel and hook, tied to 
a strip of wood in the loop of adhesive plaster below the 
foot." 

In the apparatus of Sanborn, of Lowell, Mass. (Fig. 
401), there is only the long splint used. It projects as 
far as the axilla, where it supports a crutch (a) moved by 
a screw (5); the lower end bears a bar of iron (c), project- 
ing at right angles, and also movable by a screw (d). In 
applying this splint, two long strips of adhesive plaster 
are laid upon the sides of the leg, extending from above 
the knee to a point two or three inches beyond the foot, 
and secured by a roller. The ends of the strip form a 
loop to catch upon the cross-bar, and by means of the 
screw extension can be regulated at will. The counter- 
extending band is put on in the usual manner, and it is intended by 
the crutch arrangement that, should the band press hurtfully upon 
the perineum, it may be temporarily discontinued, and the counter- 
extension established in the axilla. 




FRACTURE OF THE FEMUR. 465 

Practically, this cannot be continued effectually for any lengthy 
period, for it is instinctive on the part of a patient, in order to avoid 
this axillary pressure, and especially when it galls at all, to twist the 
shoulders to the opposite side, and thus destroy the counter-extension. 

Dr. Neill, of Philadelphia, has employed a contrivance, by means 
of which extension and counter extension may be sustained at the 
same moment. The peculiarity of the arrangement consists in the 

Fig. 402. 




Neill's apparatus. 

extending and counter-extending bands being attached to a double 
cord passing along the outside of the long splint, and which can be 
shortened at pleasure by twisting them by a short peg placed between 
them at their middle ; this apparatus is not unlike one described by 
Du Yerney. 

In some cases of fractured thigh it will be found necessary to dis- 
pense with the perineal band altogether, and then the surgeon will 
find in the adhesive strips an invaluable resource in making counter- 
extension. The peculiar plan now to be described was introduced 
into the Pennsylvania Hospital by Dr. H. L. Hodge, and found to be 
effective in the cases in which it was tried. I have employed it in 
several instances with gratifying results ; it enabled me to keep up 
efficient counter-extension, while the adhesive strips about the chest 
did not in the least inconvenience the patient further than the appli- 
cation of an apparatus requiring continuous dorsal decubitus; nor 
did it impede respiration. 

In Figs. 403, 404, it will be seen that the apparatus consists of 
an ordinary Desault's splint, wide enough at its upper end to permit 
the iron bar, fastened by bolts to its superior edge, to pass clear of 
the patient's shoulder. The bar itself is bent at right angles, as seen 
in Fig. 404, over the shoulder, so that the hook at its extremity may 
come in the line of the axis of the injured limb. A broad strip is 
now applied upon the anterior face of the chest from the groin to the 
shoulder, where a loop is left, and then continued down the back to 
the nates ; in the loop a small block is placed to keep the two parts 
of the strip separate, and also from wrinkling, that they may draw 
upon the body in parallel lines. The block is connected to an iron 
30 



466 



SPECIAL FEACTUEES. 



hook by a cord. In order to prevent the vertical strip slipping 
upwards by the tractile force, three circular strips are applied to the 
chest, as seen in Fig. 403. 

Fig. 403. 




Fig. 404. 




Hodge's apparatus for counter-extension in fracture of the thigh. 

Dr. Gilbert, of Philadelphia, has recommended the substitution of 
adhesive strips for the ordinary baud used in making counter-exten- 
sion. Fig. 405 shows his splint with the adhesive strap attached. 

Fig. 405. 





Gilbert's mode of counter-extension. 

Fig. 406 illustrates its mode of application in a case of double frac- 
ture of both thighs : 1, is the anterior counter-extending strip, two 
and a half inches wide ; 2, the end of the posterior strip, which is 
brought up in front; 3, a pelvic adhesive strip, three inches wide, 
which serves to bind the two former strips to the body; 4, the extend- 
ing strips, which form a stirrup under the foot to receive the strap 
of the tourniquet; 5, the tourniquet, for applying the extending 
power, The side-splints are applied in the usual manner with cush- 



FRACTURE OF THE FEMUR. 



467 



ions, &c, as seen in the figure. After the application of the adhesive 
strap a bandage is applied from the ankle upwards. 

Fig. 406. 




Gilbert's apparatus applied. 

Dr. Dugas, of Georgia, applies a weight to the limb for the purpose 
of making extension, and directs his apparatus to be applied in this 
manner : " Suitable compresses having been placed upon the thigh, 
apply over them four wooden splints a little longer than the femur 

Fig. 407. 




Fig. 408. 



Dugas' apparatus applied. 

(one in front, one in the rear, and one on either side), and secure them 
with many-tailed bandages or with single ties. A two or three-pound 
weight should then be fixed to the foot, 
and hung over the footboard of the bed, 
as indicated in Fig. 407, so as to keep 
up extension, while the resistance of 
the patient's body will effect counter- 
extension. A splint four inches wide, 
and extending from the side of the thorax 
to a little below the foot, will now serve 
to keep the limb straight, and to main- 
tain the foot in a proper position. This 
splint should be secured by separate ties 
passed around the abdomen, pelvis, thigh, leg, and foot. Finally, an 
arch of crossed hoops should protect the toes from the bedclothes, 

Fig. 408 shows the manner in which Dr. Dugas attaches the extend- 
ing band to the ankle. 

Dr. Gurdon Buck, of New York, makes extension with adhesive 




Dugas' mode of attaching the extending 
hand. 



468 



SPECIAL FRACTURES, 



strips, connected with a weight varying from five to twenty pounds. 
The counter-extending band is composed of an India-rubber tube, an 
inch in diameter and two feet long, stuffed with bran or cotton lamp- 
wick, and covered with Canton flannel. As seen in Fig. 409, he dis- 

Fig. 409. 




Dr Buck's apparatus. 



cards the long splint, the limb being simply enveloped in a roller 
bandage, and short splints applied to the leg. 

The methods of making extension with the gaiter and cravat, for- 
merly used (Figs. 410, 411), have, of late years, been happily dis- 



Fig. 410. 



Fig. 411. 





Mode of making extension with the gaiter. 



Mode of making extension with the cravat. 



carded; adhesive strips are now employed for this purpose, and the 
advantages over the former are incontestable, among the chief of 
which may be mentioned the simplicity of the plan, and the requisite 
amount of force being attainable without inflicting injurious pressure 
upon the insteps and margins of the foot. 

Two broad strips should be cut in the length of the plaster, and 
well stretched, so that they may not yield when applied to the leg, 
and the extending force is exerted ; they must reach well up the limb 
to get a good purchase, and have circular strips of the same material 
and a roller bandage laid over the whole, as seen in Fig. 412. 

M. Gariel, who has been instrumental in applying India-rubber to 
so many useful surgical purposes, advises, in treatment of fractures, 
the use of elastic extending and counter-extending lacs. His appa- 
ratus, as described by Jamain, is composed, 1st, of a sort of stirrup in 
the form of a circular sac embracing the ankle, and shaped in such a 
manner that when it is inflated, it is converted into a cushion exactly 



FRACTURE OF THE FEMUR. 



469 



moulded to the limb, in contact with the latter at every part of the 
surface, and consequently exercising "a perfectly uniform pressure. 

Fig. 412. 




Fig. 413. 



Mode of making extension with adhesive strips. 

This can be rendered still more gentle by the application, around 
the extremity of the limb that supports the extending stirrup, of a 
roller which possesses the double advantage of preventing the swell- 
ing of the foot, and the immediate compression of the tissues by 
the apparatus. The traction is effected by means of two exten- 
sions of the stirrup, strong cords, which, although flexible, and espe- 
cially eminently retractile, stretch sufficiently without losing their 
capacity for contraction, and thus assuring a continuous and perfectly 
exact traction; 2d, of a counter-extending lac, a tube of India-rubber 
about thirty-nine inches long, presenting at its middle point an en- 
largement destined to exercise pressure 
upon a wider surface. This enlarged 
portion ought to be placed upon the 
groin of the side of the fracture, and ex- 
tend just beyond the perineum. The ex- 
tending cords are attached to the lower 
part of the bedstead. 

Mr. Erichsen says that the starched 
bandage may be employed in most cases 
of fracture of the shaft of the femur, and 
that with the apparatus seen in Fig. 413 
he has treated many such cases, both in 
adults and children, without confinement 
to bed for more than three or four days, 
and without the slightest shortening or 
deformity being left. His manner of pro- 
ceeding is described by him thus : "A dry 
roller should be applied to the whole of 
the limb evenly and neatly, which must 
then be covered with a thick layer of 
wadding; a long piece of strong paste- 
board, about four inches wide, soaked in 
starch, must next be applied to the pos- 
terior part of the limb, from the nates to 
the heel. If the patient is very muscular, 
and the thigh large, this must be straight- 
ened, especially at its upper part, by 
having slips of bandage pasted upon it. Two narrower strips of 
pasteboard are now placed along either side of the limb from the hip 




Mode of applying the starched bandage 
in fractured thigh. 



470 SPECIAL FRACTURES. 

to the ankle, and another shorter piece on the forepart of the thigh. 
A double layer of starched bandage should now be applied over the 
whole, with a strong and well-starched spica. It should be cut up and 
trimmed on the second or third day, and then reapplied in the usual 
way." 

This method of treatment will require the greatest watchfulness by 
the surgeon, to see that no danger comes of constricting the limb, 
either from the subsequent swelling, or from too tight application of 
the roller bandage. Apparatus of the same description have been 
recommended by Seutin, Larrey, and Velpeau, as already described. 

In whatever way a fracture of the shaft of the femur is managed, it 
demands the daily surveillance of the surgeon; any injurious pressure 
of the splints upon the bony prominences of the limb must be cor- 
rected by shifting the cushions, introducing compresses between the 
limb and the splints, and the frequent application of stimulating 
washes, of which one of the best is the camphorated tincture of soap. 

The patient must be kept in the apparatus seven or eight weeks, 
though in some cases the removal may be made safely at an earlier 
period ; or, on the other hand, require it to be delayed beyond the 
time stated above. 

At first the extension should be gradual, and, in proportion to the 
capability of the patient to bear it, it must be increased to the fullest 
extent required, which perhaps may be accomplished in six or eight 
days. When the case has progressed favorably, the extending bands 
may be removed in four or five weeks, and the long splint, with a 
footboard attached, only retained, which will hold the limb securely 
until the consolidation becomes firm enough to support the weight of 
the body. At this time — in about eight weeks — the patient will be 
permitted to rise and go about upon crutches for two or three months, 
when they may be laid aside. 

With a careful patient, I have sometimes removed the straight 
splints in two weeks and applied the starched bandage, and permitted 
him to go about. 

3. Fracture of the Condyles of the Femur. — The condyles may be 
separated from the shaft of the femur at their base, or, at the same 
time that they are separated thus, another line of fracture passes 
between them. Other instances are recorded where one or the other 
condyle alone is broken from the shaft. 

Causes. — This injury is produced by the application of great vio- 
lence, falls or blows upon the knee, the passage of the wheel of a cart 
over the part, &c. 

The displacement, if the fracture is oblique, will always be of the 
lower fragment backwards ; on the other hand, this may be very little 
in transverse fracture. In separation of the condyles, lateral displace- 
ment occurs. 

Symptoms. — Preternatural mobility at the seat of fracture ; the al- 
ternate flexion and extension of the leg will produce crepitus; short- 
ening. When the condyles are separated from each other, they may 
be seized upon each side with the fingers, and moved in opposite 
directions, the motion producing crepitus ; shortening will be mani- 



FRACTURE OF THE PATELLA. 471 

fest; the knee-joint appears to have widened out, and the patella 
depressed between the condyles. 

Prognosis. — These fractures will generally be attended with violent 
inflammation in or about the knee-joint, rendering the case always 
serious. Anchylosis will perhaps be one of the most favorable results 
that can be obtained. More or less shortening must be expected. 

Treatment. — In fracture of either condyle, the limb may be placed 
in a straight position, and pasteboard or gutta-percha splints applied 
and secured with a roller. 

When the condyles are separated from the shaft, or from the shaft 
and each other, moderate extension will be required upon the limb, 
placed either in the flexed or straight position, some surgeons prefer- 
ring the former, and others the latter ; whichever plan is selected, the 
apparatus previously described will supply the means to carry it into 
effect. 

Fracture of the Patella. — Fracture of the patella is not uncom- 
mon ; the bone is generally broken in a transverse direction (Fig. 414), 
though the line of fracture may be vertical, or again run in two or three 
directions so that the patella will be divided into three or more pieces. 
(Fig. 415.) 

Causes. — In the first instance, the cause of the fracture is most com- 
monly violent muscular effort, as when a person falling backwards 
endeavors to save himself by a great effort, or in jumping or kicking; 
the transverse fracture also results from blows. Longitudinal and 
comminuted fracture is, in a majority of instances, the result of some 
direct injury, and is attended with much swelling, pain, and inflam- 
mation about the joint. 

Fig. 414. Fig. 415. 





Fracture of the patella. 

The displacement observed is a separation of the upper from the 
lower fragment, which retains its position in consequence of its con- 
nection with the tibia by the ligament of the patella. The direction 
of the displacement is upwards, and varies in amount from a few lines 
to four inches or more, according to the extent to which the aponeu- 
rosis connected with it is lacerated. 

Symptoms. — This injury is of easy recognition. The upper fragment 
can be felt to be drawn up, leaving a depression between it and the 
lower one in which the finger may be placed. If the fragments can be 
brought into apposition, crepitus may be developed by rubbing them 
together. The patient, at the time of the injury, will feel a crack, per- 
haps in the knee, and find himself unable to stand upon the limb, or 
to extend the leg. 



472 SPECIAL FRACTURES. 

Prognosis. — Union in fractured patella occurs almost always by liga- 
ment, in rare instances that by bone has been observed. The recovery 
will commonly take place without any further difficulty than perhaps 
a little stiffness of the knee, which gradually disappears. It has been 
noticed that when the separation between the fragments is consider- 
able, and connected by a long ligamentous band, the limb in the exer- 
cise of its functions will be impaired a long time, but will ultimately 
be restored to the full possession of its motions. 

Treatment. — The treatment of fractured patella consists in subduing 
local inflammation, restoring the fragments in apposition, and main- 
taining them in this position by appropriate mechanical means, until 
the union has been effected. 

The first indication is answered by the use of leeches and cold ap- 
plications. The third indication will be fulfilled by the employment 
of certain apparatus, of which there are a large number, recommended 
by various surgeons. 

Mr. Liston recommended a very suitable contrivance. The foot 
and leg, to a point just below the knee, are enveloped in a roller band- 
age to prevent swelling ; the limb placed upon a padded splint, hol- 
lowed at both ends, reaching from the tuberosity of the ischium to a 
point a little below the middle of the calf; after bringing the upper 
fragment down to its normal position, a roller is passed around the 
limb and the splint from the toes to the groin, making several crosses 
at the knee. Mr. Amesbury employed soft padded leather bands, long 
enough to go half around the limb, and having straps and buckles 
attached to their ends, by means of which they were confined to the 
limb, one upon the lower part of the thigh, and the other upon the 
leg below the knee. To the lower margin of the upper band a buckle 
is attached upon each side of the patella; corresponding to these 
buckles two straps were fastened to the upper margin of the lower 
band. By approximating the borders of the bands, the upper frag- 
ment is drawn down towards the knee. 

Instead of the wooden splint of Liston, Dr. Gross, of Philadelphia, 
recommends the employment of a padded tin case, extending from 
the middle of the thigh to a corresponding point of the calf. A rol- 
ler is to be applied upon the leg from the toes upwards, and another 
upon the thigh from the groin downwards ; the displaced fragment is 
to be brought down, and confined by numerous adhesive strips, car- 
ried around the bone above and below the joint, and connected after- 
wards by vertical and transverse pieces. A long, thick, and very 
narrow compress should extend around the upper border of the 
patella, and confined by the two rollers passed around the joint in the 
form of the figure of 8. 

Dr. Sanborn, of Lowell, Mass., suggests a way of treating a fractured 
patella by a single adhesive strip twisted above the knee. He directs 
" a strip of ordinary adhesive plaster, four feet long and two and a half 
inches wide, to be applied to the limb from the upper portion of the 
thigh to the middle of the leg, leaving at the knee a free loop (Fig. 417). 
A roller bandage is then applied above and below the knee, for the pur- 
pose of securing the plaster, and controlling the circulation and mus- 



FRACTURE OF THE PATELLA 



473 



cular contraction. A small stick six or eight inches in length then 
being put through the loop over the knee, the plaster is to be twisted 

Fig. 416. 




Sanborn's apparatus applied. 



until the patella is brought near down to its proper situation. Before 
applying the twist a hard compress is to be placed above the patella 

Fig. 417. 




The same. 

in such a manner as to bring the force to bear directly upon the 
bone." (Fig. 416.) 

One method pursued by Sir A. Cooper is seen in Fig. 418. He 
recommended that the limb should be lightly bandaged to a splint 

Fig. 418. 




Sir A. Cooper's apparatus. 

extending from the ischium to the heel, leaving the knee uncovered ; 
the thigh is then to be flexed upon the trunk, and the limb reposed 
upon an inclined plane, while the antiphlogistic remedies are to be 
had recourse to until the inflammatory swelling shall have abated 
Then a roller is to be applied to the leg, from the toes to the knee, to 
prevent engorgement; upon each side of the limb a strong tape is 
laid and confined above and below the knee by a roller bandage; 
their extremities are now to be drawn together and tied. Sometimes 
a band is put in front of the knee, and arranged in the same manner. 



474 



SPECIAL FEACTUEES. 



The same distinguished surgeon describes another apparatus (Fig. 
419) for the same purpose. A leather belt surrounds the lower part 



Fig. 419. 




Sir A. Cooper's apparatus for fractured patella. 

of the thigh above the upper fragment. To the side of this a long 
strap is attached which is intended to pass beneath the sole of the 
foot, up the opposite side of the limb, to be buckled to the thigh-belt ; 
tapes secure the strap from slipping from the leg. As in the other 
contrivance, a roller bandage is to be previously applied to the leg. 

Mr. John Wood, of London, contrived the apparatus seen in Fig. 
420. It consists of a long splint extending from the tuberosity of the 

Fig. 420. 




Wood's apparatus. 

ischium to within a short distance of the heel; from the end of this 
two short lateral curved iron bars extend, supporting a footboard, and 
bent at right angles to be fixed to a block which raises the splint from 
the bed. To each side of the splint two hooks are fastened, one above 
the knee and the other below. 

In applying the apparatus the splint is well padded and the limb 
laid upon it ; a roller bandage is now applied from the toes upwards, 
arriving at the knee, after the fragment has been drawn down, the 
roller is made to form a figure 8 about it, the turns of which are pre- 
vented from slipping by the hooks. 

Prof. Hamilton has adopted a much better form of splint than the 
preceding, and one I have used in three cases with decided success. 
It is seen in Fig. 421, and he describes it in the following language: 
" The dressing consists of a single inclined plane, of sufficient length 
to support the thigh and leg, and about six inches wider than the 
limb at the knee. This plane rises from a horizontal floor of the 
same length and breadth, and is supported at its distal end by an 



FRACTURE OF THE PATELLA 



475 



upright piece of board, which serves both to lift the plane and to 
support and steady the foot. The distal end of the inclined plane 
may be elevated from six to eighteen inches, according to the length 
of the limb and other circumstances. Upon either side, about four 

Fig. 421. 







Hamilton's apparatus. 

inches below the knee, is cut a deep notch. The foot-piece stands at 
right angles with the inclined plane, and not at right angles with the 
horizontal floor ; it may be perforated with holes for the passage of 
tapes or bandages to secure the foot. 

" Having covered the apparatus with a thick and soft cushion care- 
fully adapted to all the irregularities of the thigh and leg, especial 
care being taken to fill completely the space under the knee, the whole 
limb is now laid upon it, and the foot secured gently to the footboard, 
between which and the foot another cushion is placed. 

" The body of the patient should also be flexed upon the thigh, so 
as the more effectually to relax the quadriceps femoris muscle. 

" A compress made of folded cotton cloth, wide enough to cover 
the whole breadth of the knee, and long enough to extend from a 
point four inches above the patella to the tuberosity of the tibia, 
and one-quarter of an inch thick, is now placed on the front of, and 
above the knee. While an assistant presses down the upper fragment 
of the patella the surgeon proceeds to secure it in place with bands of 
adhesive plaster. Each band should be two or two and a half inches 
wide, and sufficiently long to inclose the limb and splint obliquely. 
The centre of the first band is laid upon the compress partly above 
and partly upon the upper fragment, and its extremities are brought 
down so as to pass through the two notches on the side of the splint 
and close upon each other underneath. The second band, imbricating 
the first, descends a little lower upon the patella, and is secured below 
in the same manner. The third, and so on successively until the 
whole extent of the compress and knee is covered, is carried more 
nearly at right angles around the leg and splint ; the last bands pass- 
ing obliquely from below the ligamentum patella? upwards and back- 
wards. The dressing is now completed by passing a cotton roller 
around the whole length of the limb and splint, commencing at the 



476 



SPECIAL FKACTUKES, 



toes and ending at the groin. This is applied lightly, as its object 
is only to support and steady the limb upon the splint." The supe- 
riority of this apparatus is that it does not obstruct the circulation by 
constricting the limb, as there is ample space between the bandage 
and sides of the limb. 

A rather complicated apparatus was employed by Mr. Lonsdale, 
but it has the recommendation of being efficient (Fig. 422). 

Fig. 422. 




Lonsdale's apparatus for fractured patella. 

It consists of a well-padded splint extending along the posterior 
surface of the limb, and supporting at its further end a footboard 
which may be moved up or down to accommodate the splint to limbs 
of different length. From the bottom of the splint in the neighbor- 
hood of the knee-joint two vertical metallic bars, A B, project, each 
bearing an iron stem, Gr Gr, bent at right angles moving upon it, and 
capable of being fixed at any point by the thumb-screw, C D — the 
two portions of the stems in the axis of the limb support sliding pins 
having attached to their inferior extremities padded metal plates of 
a semilunar shape, intended to press upon the fragments above and 
below. In employing the apparatus the limb is laid upon the splint 
and secured to it by a roller bandage, and after the upper fragment 
is drawn down the semilunar pads are placed against the upper and 
lower borders of the patella and fixed by the screws. To relax the 
quadriceps femoris, the lower end of the splint is raised from the 
mattress upon a little frame. 

Surgeon P. Lansdale, U. S. Navy, has invented a very ingenious 
and efficient splint seen in Fig. 423. It holds the fragments in exact 

Fig. 423. 




Lansdale's apparatus. 



apposition, and does not constrict the limb. It is constructed with a 
posterior padded splint upon which the limb is secured with a roller 



FRACTURE OF THE PATELLA. 



477 



bandage. From a point a short distance above the knee an iron loop 
or arc spans the limb obliquely, and, when in position, its top is below 
the patella ; a similar arc is fastened to the splint at a corresponding 
point below the knee, and its top, when in position, is above the knee. 
Each of these arcs bears a screw at its centre armed with a semilunar 
pad. In the application of this apparatus after the limb is secured to 
the splint, it is simply necessary to bring the upper fragment down, 
and with the upper screw clamp the pad against it ; in like manner 
clamp the inferior fragment with the lower pad. This holds the 
pieces of the patella firmly together so that it is impossible for them 
to escape. 

M. Malgaigne, struck by the general inefficiency of the apparatus 
employed in France for fractured patella, devised the instrument seen 
in Fig. 424. It consists of two pairs of sharp- 
pointed hooks movable towards each other by a Fig. 424. 
screw, and intended to take their point oVappui di- 
rectly upon the bony fragments above and below. 

In applying the instrument the hooks are thrust 
through the skin down to the margins of the frag- 
ments, and by the action of the screw these are 
brought into close contact and retained in this posi- 
tion six weeks, or until their union is accomplished. 

I have employed Malgaigne's apparatus in one 
case with decided success ; and there were no trou- 
blesome symptoms presented during the treatment, 
which, I must confess, at first, I feared would occur 
from the proximity of the hooks to the knee-joint. 

A very simple but efficient application of the 
Spanish windlass or handkerchief and stick arrange- 
ment to the back splint, in the treatment of trans- 
verse fracture of the patella, is recommended by 
Dr. Edward Hartshorne, who has employed it with 
great advantage in hospital and private practice, 
having used it first in the Pennsylvania Hospital in 
1862. 

The splint, which should, of course, be carefully padded, is not 
peculiar, except that, in accordance with an old rule, it is always 
broad enough above and below the knee to prevent the bandages 
from constricting or pressing on the sides of the limb in their passage 
backwards from the margins of the patella ; and is also furnished on 
its sides, at proper distances, above and below the knee, with the 
notches or projecting cleets, pins, or hooks which are required to hold 
the bandage. This bandage may be the common roller or adhesive 
strips, or even a band or ring of elastic webbing ; but inelastic webbing, 
or linen, or cotton drilling from one and a half to two inches wide in 
the central portion and narrower at its ends, answers better, especially 
if the surfaces which we apply to the integument above and below 
the fragments are thinly spread with old adhesive plaster. The lower 
fragment is fixed in the usual way, and retained in position by simply 
applying one of the bandages by its wider central portion in front of 




Malgaigne's apparatus 
for fractured patella. 



478 SPECIAL FRACTURES. 



the knee-joint directly to the lower margin of this fragment, then 
passing the two narrower ends obliquely upwards and backwards and 
drawing them firmly together over the upper cleets, pins, or notches, 
and behind the splints, there to be fastened in any manner most con- 
venient. 

The bandage or band for the upper fragment requires more careful 
application and adjustment, as it is to exert all the pressure and trac- 
tion force necessary to bring the fragment down, and retain it in 
apposition with the fixed lower fragment. Having been applied to 
the integument just above and slightly over the margin of this upper 
fragment, it is then drawn firmly downwards and forwards over the 
notches or cleets in such an oblique direction as may be found the 
best for efficient traction in each particular case. The two ends are 
firmly fastened together, and a small stick (or, what is better, the little 
wooden fork called a clothes-pin), passed between the band and the 
splint, is turned or twisted on its long axis in such a way as to draw 
upon the bandage to any proper extent. This arrangement allows 
the whole knee, especially the injured parts and the compressing 
bandages, to remain uncovered, at the same time that it gives entire 
control of the joint and of the separated fragments, as well as of the 
dressing itself. Compresses of lint or other material may be employ- 
ed, but they are not often needed, particularly when adhesive plaster 
is spread upon the central portion of the bandage. Tilting of the 
fragments may be prevented by a transverse bandage, or by a narrow, 
well-padded transverse splint pressing upon the line of fracture. The 
ease and certainty with which the traction may be lessened or increased 
by the slightest turn of the twisting-stick or pin, at the same time 
that this pin may be fastened beyond the reach or control of the 
patient, renders this contrivance remarkably effective ; while the sim- 
plicity of materials and arrangement bring it readily within the reach 
of every one. The same care in all essentials, and especially in adapt- 
ing the splint and bandage, as to length and width of the former, and 
the distance apart of the cleets or notches, and the width and ob- 
liquity of the latter, must be observed in the use of this mode of 
dressing, as in other more complex or different arrangements. Dr. 
Hartshorne's method has been tried sufficiently often under his own 
observation, to satisfy him that it works well in every respect; 
having been found very comfortable to patients, even after considera- 
ble inflammation of the soft parts, and under long-continued, close 
approximation of the fragments ; requiring less attention than usual 
in maintaining the adjustment; and being followed, in several in- 
stances, by inappreciable separation, if not actual consolidation. 

Various contrivances for graduating traction behind the splint, or 
on its sides — such as wedges, screws, buttons, elastic rings or straps, 
as well as neater forms of wooden or metallic, and guttered splints in 
the usual shapes — might be suggested; but they are all objected to 
by Dr. Hartshorne, on account of their complexity and costliness, from 
which his bandage and stick are free. 

To meet the desire for a more convenient and comfortable dressing, 
especially during convalescence, and in case of injurious separation 






FRACTURE OF THE PATELLA. 479 

of the fragments from defective treatment, he has, with the aid of 
Mr. Kolbe, devised a light tin case, fitting to the limb behind, lacing 
in front of the thigh and the leg, and being provided with straps 
(elastic or not, according to circumstances), which are to be applied, 
as usual, across the joint, above and below the patella, and drawn 
obliquely to be fastened and tightened by means of a wedge or screw. 
Such an apparatus, properly made, would be found ygtj convenient 
to those in whom the treatment is sufficiently advanced to admit of 
moving about, as well as to all patients who are willing to indulge in 
the expense of an unnecessarily luxurious kind of splint. 

Dr. Hartshorne has applied the same dressing in a still simpler 
form, with entire success, to the treatment of fractured olecranon. In 
this fracture, as in the other, the splint must be wide enough below 
the elbow-joint to avoid constriction, and but one bandage and one set 
of notches or projecting cleets are needed. The application of the 
bandage, which is evident enough, has been found to work admirably. 
The Spanish windlass may be usefully resorted to, as it doubtless has 
been, in the production of compressing force for different purposes in 
other parts of the body. Dr. Hartshorne has found it an excellent 
substitute for Malgaigne's screw-pin and collar in managing the trou- 
blesome displacement of the lower fragment in oblique fracture of the 
tibia. With a sufficiently wide and well-padded splint, and a judi- 
cious employment of compresses, he has been able to effect very 
nearly, if not quite as much by means of the bandage and stick, as 
can be done either with the saddle-shaped pads, with which Dr. Prince 
has improved upon the pointed screw of Malgaigne, or with the latter 
more formidable instrument. 

The foot ought to be supported, at least in the early stages of treat- 
ment of fractured patella. It may be effected either with a long 
splint furnished with a footboard, with a fracture-box or trough, with 
a footboard attached to the bedstead, or with plenty of pillows. This 
support is not indispensable, but it is advantageous and comfortable. 

In carrying out the mechanical treatment of fractured patella, 
Dr. Hartshorne has secured, by his apparatus, several important ad- 
vantages. He avoids circular and lateral constriction, keeps the parts 
in view uncovered and cool, with room for lotions, if desirable, and 
produces and maintains ample traction in a sufficiently effective direc- 
tion, taking care to prevent tilting, and to cause a close approxima- 
tion of the fractured surfaces, all with the simplest possible means and 
materials. He does not elevate the extremity, nor very strongly ex- 
tend the leg. Both of these positions, elevation and extension, are 
uncomfortable, fatiguing, and unnecessary. 

In fracture of the patella it will be necessary to continue the splint 
seven or eight weeks, at the lapse of which time daily passive motion 
must be inflicted upon the knee-joint. The patient may be permitted 
to get up and go about on crutches, but, in order to avoid stretching 
of the ligamentous band, the limb should be kept extended by a 
straight splint applied to its posterior surface for two or three weeks 
more. 



480 



SPECIAL FRACTURES, 



Fracture of the Tibia and Fibula. — Fracture of the tibia and 
fibula constitutes more thau half the cases of this sort of injury affect- 
ing the bones of thejeg. It is here that we meet with a large propor- 
tion of compound and comminuted fractures. Both bones may be 
broken at the same or different heights ; in the first instance (Fig. 425) 



Fig. 425. 



Fig. 426. 





Fractures of the tibia and fibula. 



the fracture will be found usually located at the junction of the upper 
with the middle third, and in the latter the tibia will usually give 
way in the lower third and the fibula in its upper, as seen in Fig. 426. 

The line of fracture is, in a majority of cases, oblique, yet it is 
sometimes transverse, and will then occur usually at some point in 
the upper third of the tibia ; the fracture of the fibula is almost always 
oblique. 

Causes. — The commonest cause of fracture of the leg is the appli- 
cation of direct violence, as the fall of a heavy weight upon the limb, 
the rolling of the wheel of some sort of vehicle over it, heavy blows, 
&c. Again, a person's weight coming upon the soles of the feet in 
jumping from a height will also produce the fracture. It is in those 
cases from direct injury that fracture of both bones at the same level 
is commonly observed, and the reverse in fracture from contrecoup. 

The nature of the displacement will depend upon the direction of 
the line of fracture and the sort of force producing it. When the 
line is transverse, there will be little else than perhaps some lateral 
deflection of the ends of the fragments in opposite directions, and the 
limb not shortened. When it is oblique, which it generally is, and in 
a direction downwards and forwards, the lower fragment will be drawn 



FRACTURE OF THE TIBIA AND FIBULA. 481 

upwards by the muscles of the calf of the leg, and thus produce slight 
shortening. In this instance the top of the superior piece will project 
in front beneath the skin ; sometimes will perforate it, rendering the in- 
jury compound. Angular displacement anteriorly is also seen in certain 
cases, and is caused by the contraction of the quadriceps femoris or 
the gastrocnemius, and sometimes by the weight of the foot alone, the 
former muscle acting with greater energy as the fracture is nearer the 
knee. Should the foot be twisted inwards or outwards, the lower 
fragment will be rotated upon the upper. 

Symptoms. — The symptoms denotive of fracture of the leg are pre- 
ternatural mobility at the seat of fracture, deformity when the foot is 
raised, irregularity upon the anterior border of the tibia and outer 
edge of fibula when the fingers are run along them, slight shortening, 
and crepitus evolved by rotating the leg. The patient cannot bear 
his weight upon the limb, and efforts to do so cause excruciating pain. 

Prognosis. — Fracture of the tibia and fibula will generally unite 
well in about thirty days without any difficulty, while in certain cases 
it may be delayed a much longer period. Compound and comminuted 
fractures are liable to become complicated with inflammation and sup- 
puration, erysipelas, necrosis of the ends of the fragments, and in one 
case I saw tetanus occur on the seventh day and kill the patient. It 
occasionally happens, in some of these complicated fractures, that a 
crooked leg will result in spite of the best treatment. 

Treatment. — The treatment of this injury has been variously con- 
ducted, as regards the position of the limb and the construction of 
apparatus for retaining the ends of the bones in contact while con- 
solidation is being effected. Most surgeons prefer the straight position 
of the limb as meeting more fully all the indications presented in this 
fracture, and either do or do not make extension and counter-extension, 
according to their views of the necessities of the case. 

One of the simplest dressings, with the leg in the straight position, 
and without making extension or counter-extension, is prepared in 
the following manner : Spread upon a pillow, on which the leg is to 
repose, a piece of cotton cloth long enough to reach from the lower 
third of the thigh to the ankle, and sufficiently wide to encircle the 
limb twice; over this lay as many strips of the same material as will 
reach from the ankle to the knee, each strip being imbricated and 
sufficiently long to go around the limb once and overlap two inches 
upon either side; the leg is now placed upon the dressings, and 
inclosed by bringing the strips around it in the same manner as in 
the bandage of Scuitetus. Three cushions of oat-chaff or long com- 
presses of lint are placed upon each side and front of the limb, and 
held in place while an assistant makes extension from the foot, to 
bring the displaced fragments end to end; the surgeon will then roll 
up in the splint-cloth, from its ends towards the leg, two splints of the 
same length as the cloth, and bring them firmly against the cushions,, 
and place a narrow splint in front of the leg; three strips of bandage 
are now applied, to bind the whole together. To prevent the foot 
from falling to either side, a cravat may be folded around the foot,. 
and its ends pinned to the splint-cloth. Instead of wooden splints, 
31 




I 



482 SPECIAL FRACTURES. 

wheat-straw may be rolled up in bundles and used for the same pur- 
pose as the splints. 

This apparatus will be found exceedingly convenient in cases of 
emergency, and I was in the habit of employing it often during the 
late war, under circumstances where other more appropriate means 
were not attainable. 

The fracture-box is another simple contrivance, and will be found 
to answer well in most cases. It consists, as seen in Fig. 427, of an 

oblong wooden box of four sides, 
Fig. 427. reaching from a little above the knee 

to the sole of the foot; the lateral 
sides, six or seven inches wide, are 
attached to the bottom by means of 
hinges, which permit them to be 
raised or lowered, as desired; the 
fourth side projects upwards, and 
serves the purpose of a footboard. 
The fracture-box. In employing the box, the sides 

are lowered to a level with its bot- 
tom; a pillow is placed upon it, and the leg upon the pillow; extension 
is now made until the fracture is reduced, when the sides of the box 
are raised and the edges of the pillow pressed evenly upon the lateral 
surfaces of the leg. Three strips of bandage are passed around the 
box, to bind it together, and knotted upon one of its edges ; the foot 
is held to the footboard by a strip of bandage. 

If there is any discharge from the leg, to prevent it soiling the 
pillow, a piece of oiled silk may be interposed between them. 

The fracture-box has been highly recommended by Dr. J. Ehea Bar- 
ton in compound fracture, but he employs, instead of the pillow, a 
quantity of bran, which should surround and cover the leg. This 
dressing possesses the advantages of affording the limb uniform sup- 
port in every direction, does not produce excoriation or ulceration of 
the heel, and keeps the flies from depositing their ova in the suppu- 
rating wound, which they are exceedingly apt to do in hot weather. 
I used, in the same manner, fine pine sawdust in a case of compound 
fracture of both legs, and believe it equally as serviceable as the bran, 
over which it possesses the merit of being more absorbent, and, I 
believe, forms a cooler bed for the leg to repose in, and does not be- 
come sour. 

The leg should be inspected daily, and any tendency to angular 
deformity corrected by proper compresses placed beneath the tendo- 
Achillis and heel. It should not be forgotten, however, that these 
compresses may produce injurious pressure upon these parts, and 
cause ulceration, a result only to be avoided by either removing the 
pressure entirely, or making it as uniform and soft as possible. 

Should it be deemed advisable to make compression upon the leg, 
or to facilitate the application of lotions of the acetate of lead or other 
dressings, the bandage of Scultetus, applied directly to the limb, will 
answer better than anything else. 

If the lower end of the upper fragment will project forwards in 



FEACTURE OF THE TIBIA AND FIBULA. 



483 



spite of these efforts of the surgeon, he will sometimes succeed in 
keeping it in position by bringing pressure to bear upon it by the 
tourniquet of Petit, its pad being placed over the bone, and the strap 
buckled around the box. 

After the dressings are applied according to the requirements of 
the case, some degree of general movement of the leg may be obtained, 
without affecting the relations of the fragments of bone to each other, 
by swinging the fracture-box from a horizontal bar supported above 
it by a frame, as seen in Fig. 428. 

Fig. 428. 




Mode of suspending the fracture-box. 



A better form of a swinging apparatus is seen in Fig. 429, in which 
the cradle is supported upon the horizontal bar by two little wheels, 

Fig. 429. 




Another form of suspensory apparatus for fracture of the leg. 

that permit vertical as well as lateral motion, and thus remove the 
danger of the upper fragment being thrust over the lower. 

The "anterior splint" of Prof. N. R. Smith will also be found an 



484 



SPECIAL FEAOTUEES. 



Fig. 430. 



admirable means in many cases of compound fracture of the leg. It 
permits the seat of fracture to be constantly exposed to the examina- 
tion of the surgeon, does away with 
all nndue pressure and its results 
upon the heel, andj lastly, facilitates 
the cleansing and dressing of the 
parts. 

The starch, gutta-percha, plaster, 
or dextrine bandage may be em- 
ployed in simple fracture of the leg 
after two or three days, when the 
inflammation and tumefaction have 
subsided. I usually apply this 
bandage in almost all cases of frac- 
tures of the leg, when the discharge 
and wounds, if any, have been got- 
ten rid of in other apparatus, and 
permit the patient to go about upon 
crutches. For safety, I always use 
a bivalved apparatus, padded with 
cotton-batting, and secured to the 
leg and foot by the roller bandage. 
In this arrangement the parts may 
be examined at any time without 
disturbing the limb, which is permitted to repose in one of the sec- 
tions while the opposite one is removed. 

In those instances of fracture where the fragments persistently over- 
lap, it has been recommended by some surgeons to employ extension 
and counter-extension. Several plans have been devised for this pur- 
pose. Dr. James Hutchinson contrived an apparatus that has been 
much employed in this country, but now almost abandoned, and very 

Fig. 431. 







Starched apparatus in fracture of the leg. 




Hutchinson's apparatus for fracture of the leg. 

justly, inasmuch as bad consequences were frequently observed to fol- 
low the constriction exercised by the band encircling the leg below 
the knee. 



FRACTURE OF THE TIBIA AND FIBULA 



485 



This apparatus consists of two side-splints, extending from a little 
above the knee to a point three or four inches beyond the sole, con- 
nected below by a transverse piece fitting into mortises at their ends. 
The proximal ends of the splints are perforated with holes for the 
counter-extending bands. Its application requires the leg to be enve- 
loped in a bandage of Scultetus, and placed upon a pillow; tapes are 
then laid upon each side of the leg and confined by a roller beneath 
the knee, and a gaiter placed upon the foot or a cravat made to encir- 
cle the ankle for making the extension. Cushions are placed inside of 
the splints, the counter-extending tapes passed through the apertures 
in their upper extremities and tied, when the fracture is reduced, and 
maintained so bv fastening the ends of the extending cravat to the 
cross-bar. Two or three pieces of bandage are now tied around the 
splints and leg to bind the whole together. 

Dr. Neill employs extension and counter-extension in the following 
manner : " For simple fracture of both bones of the leg, attended with 

Fig. 432. 




Weill's apparatus for fractured leg. 

shortening and deformity, not easily overcome, the limb should be 
placed in a long fracture-box (Fig. 432), with sides extending as high 
as the middle of the thigh, and a pillow should be used for com- 
presses. 

" The counter-extension is made by strips of adhesive plaster, one 
inch and a half in breadth, secured on each side of the leg below the 
knee, and above the seat of fracture by narrow strips of plaster ap- 
plied circularly. The end of the counter-extending strips may then 
be secured to holes in the upper end of the sides of the fracture-box, 
by which the line of the counter --extension is rendered nearly parallel with 
the limb." 

Extension is made with adhesive strips in the usual manner. 

Fig. 433. 




Neill's apparatus for compound fractures of the leg. 



In compound fractures, where extension and counter-extension are 
required, and certain dressings to the injured parts, he employs the 



486 SPECIAL FKACTTJKES. 

apparatus seen in Fig. 433. It differs from the preceding apparatus, 
in that its sides are sawn through at the knee, and the lower sections 
fastened to the bottom by binges, so that they may be lowered and 
expose the leg without disturbing the tension of the extending and 
counter-extending bands. 

Mr. Fergusson is very favorably impressed with the utility of an instru- 
ment constructed by Mr. Weiss, of London. It yields ample support to 

Fig. 434. 




Weiss's apparatus for fracture of the leg. 

the limb ; having a footboard prevents the toes from turning inwards 
or outwards ; is cheap, light, and portable, and with slight modifica- 
tion may be employed in the treatment of fracture of the patella or 
thigh. 

" The bars and foot- piece consist of iron, the screws of brass ; the 
long bar is of an average length, to extend between the knee, and be- 
yond the sole of the foot ; the board is so attached that it can be slid 
upwards or downwards at will, and then be fastened by the side screws; 
it can also be moved in a lateral direction, so as to evert or invert the 
toes ; and, moreover, it can be placed at such a distance from the splint 
at the ankle as may be found best suited to the thickness of the 
patient's limb. The cross-bar below prevents the member from rolling 
outwards or inwards, and by means of the screw the side-splint and 
foot may be raised or depressed, as may be found most convenient. 
The bar may be attached to the screw at the knee, where it will some- 
times be found to answer best; or two may be used, one above and 
one below, each being of service to raise the part over it to any required 
height. In the cut a small portion of another side-bar is exhibited ; 
this is of the same size and shape as that above described, and is in- 
tended to act as a thigh-splint in cases of fracture here, or when it 
may be desired to apply extension in fracture of the leg." 

The accompanying drawing (Fig. 435) shows the manner in which 
the apparatus is applied. The side-splint is, however, wider than that 
described above, a modification which Mr. Fergusson has deemed 
necessary in certain cases. 

Dr. Welsh's veneered gutta-percha splints (Fig. 436) for fracture of 
the leg are also a useful contrivance, giving equable support to the 
whole leg and foot, and will be found of especial value in those cases 
of fracture involving the knee and ankle-joints. 

Dr. Bauer, of New York, has also devised iron wire splints (Fig. 437), 
which not only sustains the parts accurately, but, according to this gen- 



FRACTURE OF THE TIBIA AND FIBULA. 487 

Fig. 435. 







\NM^P"^f? 




Fergussoa's modification of Weiss's apparatus. 



tleman. possess the further merit of permitting the insensible perspira- 
tion to escape freely through its meshes, and allowing the applications 

Fig. 436. 




Welsh's apparatus for fractured 



of water-dressings without impairing the strength of the splint. With 
proper care, however, application of remedial agents may be made as 

Fig. 437. 




Bauer's apparatus for fractured leg. 



well while using other forms of splints as those of wire — and as these 
are always covered upon those surfaces in contact with the skin with 
cotton-batting, or other absorbent materials, the perspiratory secre- 
tions are readily taken up. 

As the displacement of the fragments results either from the direc- 



488 SPECIAL FEACTUEES. 

tion of the line of fracture or muscular contraction, it has been recom- 
mended by some surgeons to flex the limb, and thereby relax the mus- 
cles causing the displacement, especially wheji the line of fracture is 
from above downwards and from before backwards. Mr. Erichsen says, 
that in these cases the bones may usually be got into excellent posi- 
tion by flexing the thigh well upon the abdomen, and the leg upon 
the thigh, so that the heel nearly touches the nates, and then laying 
the limb on its outer side, on a wooden leg-splint, provided with a pro- 
per foot-piece, and keeping it fixed in this position. 

During the war, a large number of cases of compound fracture 
of the tibia and fibula coming under my care, I placed five with the 
leg in a bent position upon Pott's splint. (Fig. 438.) I succeeded well 

Fig. 438. 




Pott's angular splint for fractured leg. 

in keeping the fragments in apposition, and four were cured with an 
average shortening of half an inch ; in the fifth there was no appre- 
ciable shortening. 

The mode of dressing pursued was the employment of an outside 
splint about seven inches wide, reaching from above the knee to the 
sole of the foot, with an angular projection from this point to the tips 
of the toes to support the foot. This splint was well padded with cot- 
ton-batting, with an excavation for the external malleolus, so as to 
relieve it from all pressure. This was placed upon the outside of the 
limb so as to bring the inner border of the great toe in line with the 
inner border of the patella, the thigh having been previously bent 
■upon the abdomen, and the leg at right angles with the thigh ; upon 
the inside of the leg a padded pasteboard splint was put, extending 
from the knee to the upper border of the internal malleolus ; a roller 
bandage was now applied from the toes upwards, leaving the seat of 
the fracture uncovered. 

If the parts needed support, I used the bandage of Scultetus, applied 
directly to the leg from the ankle to the knee, and if there was much 
discharge, I interposed a piece of oiled silk between the limb and 
splint to protect the latter. 

When the apparatus was completed the limb was placed upon its 
outer side, to which the body was also inclined, though the patients 



FRACTURE OF THE TIBIA AND FIBULA. 489 

often changed this position to dorsal decubitus without disturbing the 
relations of the fragments. 

The double-inclined plane, with the footboard attached, already de- 
scribed, may be also employed in the treatment of this fracture. 

Mr. Fergusson gives decided preference to the apparatus of Mr. 
M'Intvre, as modified by Mr. Liston. It consists of a thigh and leg- 
piece of sheet iron, and a footboard of wood ; the former are joined 




M'lntyre's apparatus for fractured leg. 

to each other by a couple of hooks, and a screw, which is so placed 
that the two plates can be set to any angle at which it may be desira- 
ble to bend the knee, and the footboard is affixed in such a manner 
that it may be slid upwards or downwards to suit the length of the 
leg, and fastened by a side-screw in any position that may be desired. 
At the lower end of the machine there is a cross-plate of iron, which 
is so attached that, in the event of the foot being raised or depressed, 
it will always rest flatwise on the mattress, or a board placed at the 
foot of the bed for the purpose of supporting it. 

The instrument is applied by placing upon it suitable cushions upon 
which to repose the limb after the fracture has been reduced ; intro- 
duce compresses to rectify any malposition of the fragments if that 
should exist, and to equalize the pressure over the leg ; then apply a 
roller bandage from the toes upwards, leaving the seat of injury in- 
creased, if the fracture is compound, and attended with discharge. 
Extension may be made according to the necessities of the case. 

From the construction of this apparatus it may be used either as a 
straight splint or as a double-inclined plane. 

There is sometimes great difficulty encountered, in oblique fracture 
from above downwards, and from before backwards, in keeping the 
lower point of the upper fragment in position; it projects beneath the 
skin, and may perforate it, thus rendering an otherwise simple fracture 
compound. Malgaigne has proposed an apparatus (Fig. 440) to remedy 
this. It consists of an arc of steel sufficiently long to span three-fourths 
of the circumference of the leg; through its centre a sharp-pointed metal- 
lic screw works, which also slides in a fenestrum, so that its position may 
be varied in such a manner that the point may always be forced against 
the bone perpendicular to the shaft of the tibia. The extremities of 
the arc have two horizontal mortises for the attachment of a strap. 
The instrument is applied by placing the limb upon a well-padded 



490 



SPECIAL FRACTURES^ 



double-inclined plane; the arc is put over the seat of fracture, and 
then secured in position by the strap buckling around the splint. By 

Fig. 440. 




Malgaigne's apparatus for fractured leg. 



turning the head of the screw the sharp point is pressed against and 
into the tip of the projecting fragment. 




The same applied. 

Malgaigne says that the patient feels moderate pain at the moment 
the puncture occurs, but that it soon diminishes. The limb should be 
kept quiet, and the instrument will remain implanted in the bone 
fourteen, twenty, and even thirty-six days without determining sup- 
puration, inflammation, or even redness. When the apparatus is 
removed the puncture in the skin cicatrizes in twenty-four hours. 

Fkactube of the Tibia. Causes. — Fracture of the tibia is gene- 
rally caused by direct violence, such as heavy blows, the kicks of a 
horse, &o. The weight of the body coming upon the sole of the foot, 
as occurs in jumping from a height, is the indirect cause sometimes 
observed. The point of fracture may be in the shaft or at either 
extremity; its direction, in the former instance, is ordinarily trans- 
verse; in the latter, oblique, and not unfrequently running into the 
knee or ankle-joints. Fracture of the shaft is seen, in a majority of 
cases, in its middle third. 

Symptoms. — As the fibula remains intact, it serves as a sort of 
splint to the tibia, so that little or no displacement can occur. The 
symptoms will be obscure, though, if the case is seen early, some 
irregularity may be felt upon the surface of the tibia, and perhaps 
obscure crepitus developed. 



FRACTURE OF THE FIBULA. 



491 



Prognosis. — Fracture of the shaft will unite promptly without de- 
formity, while in those cases where the knee or ankle-joints are 
involved, anchylosis should always be feared. 

Treatment. — When the fracture is oblique from above downwards 
and from behind forwards, penetrating the knee-joint, Sir A. Cooper 
recommended that, in order to relax the quadriceps extensor, which 
throws the upper fragment forwards, the limb be placed in a straight 
position, and a pasteboard splint be applied, embracing the lower 
third of the thigh, knee, and upper part of the leg. 

In the contrary case, where the line of fracture is in a reverse direc- 
tion, the deformity is caused by the gastrocnemius drawing up the lower 
fragment, and therefore the limb should be placed upon a double- 
inclined plane to relax this muscle, while the weight of the leg will 
act as an extending force. In regard to this latter point, however, it 
may be added, that extension in these cases is quite unnecessary. 

A simple straight splint will usually answer, in a majority of cases, 
all the indications presented by a fracture of the shaft of the tibia. 

An oblique fracture into the ankle-joint, attended with eversion or 
inversion of the foot, requires the application of a splint in the manner 
directed for fracture of the fibula, being put upon that side of the 
limb opposite the direction in which the foot is deflected; that is, if 
the foot is everted, place the splint on the inside of the leg, and the 
reverse if it is inverted. 

Prof. Gross recommends a tin case, accurately fitting the foot and leg, 
and extending above the knee. (Fig. 442.) It is padded, and fastened 



Fig. 442. 



Fig. 443. 





Gross's tin splint. 



Wire splint. 



to the limb by a roller bandage. The wire splint seen in Fig. 443 
is also an elegant and efficient contrivance for such cases, and it is the 
one I am most in the habit of employing. 

Fracture of the Fibula. — Fracture of the fibula may occur at 
any part of its extent, though it is by far most common in the lower 
fourth. In the upper three-fourths the fragments will be sustained by 
the tibia, and therefore little displacement can occur. The symptoms 
are pretty much those of a similar injury of the tibia, and the treatment 



492 



SPECIAL FRACTURES. 




Fracture of the 
fibula. 



Fig. 444. requires the leg to be kept quiet in simple straight splints 

or a starched apparatus until the consolidation is effected. 

In the lower fourth of the bone (Fig. 444) the fracture 

is quite another thing, both as regards its prognosis and 

treatment. 

Causes. — In the majority of cases the fracture will be 
found to result from indirect force — falls upon the feet, 
false steps, &c; sometimes, also, blows upon the outer 
edge of the leg will produce the same result. 

The mechanism of the fracture depends upon the 
position of the foot at the time the weight of the body 
comes upon it, for if this is everted, the os calcis being 
turned outwards, will press the lower extremity of the 
fibula upwards, and a fracture will result in the fibula 
about three inches above the lower extremity ; on the 
other hand, the weight of the body falling upon the in- 
verted foot, will cause the astragalus to rotate outwards 
against the external malleolus, and break the bone near 
the same point. 

The fracture is usually complicated with a rupture of the deltoid 
ligament, or a fracture of the lip of the inner malleolus, or a fracture 
of the entire inner malleolus, the line of separation occurring from 
without inwards and downwards. 

Symptoms. — The symptoms will vary according to the nature of 
these complications. In the first case, that of fracture of the fibula with 
rupture of the internal lateral ligament, the pain will be severe, and 
the ankle much swollen ; the patient cannot bear his entire weight 
upon the foot, which will be slightly everted ; a depression will be 
felt over the seat of fracture, and indistinct crepitus may be evolved 
by moving the foot. When the tip of the malleolus is broken off, in 
connection with these symptoms, a depression will exist above the 
detached fragment. Lastly, in these cases, when the inner malleolus 
is obliquely fractured, the toes will be everted, the foot much rotated 
out, and, when grasped in the hand, may be readily moved in any 
direction, and, at the same time, these motions will emit distinct 
crepitus. The malleoli will be widely separated, giving the ankle the 
appearance of an increased width. 

Prognosis. — All of flhese injuries will be attended with more or less 
stiffness of the joint after the apparatus is removed, which in a few 
months will generally disappear. In one case that came under my 
care, where the inner malleolus was also fractured, after the bones 
had united without deformity, and considerable motion was restored 
to the joint, the patient could not, at the lapse of nine months, bear his 
weight upon the foot without the assistance of an apparatus I subse- 
quently contrived for him. 

Compound fractures from direct violence frequently require ampu- 
tation, and will generally result, if the foot is saved, in anchylosis. 

Treatment of fracture of the lower fourth of the fibula. — If there is 
much inflammatory action, lay the leg in an easy position upon a 
pillow, and apply leeches, cold water-dressings, or other antiphlogi sties, 



FRACTURE OF THE TARSAL BOXES, 



493 



and, when the swelling has abated, apply the apparatus required, of 
which none are better than that of Dupuytren when the foot is rotated 
either outwards or, as it sometimes is, inwards. (Fig. 446.) 

The splint, which is to be placed upon that side of the limb opposite 
to that to which the foot is turned, should extend from the knee to 
four inches beyond the foot, about three wide and half an inch thick; 
a pad, with the thick end downwards, must be interposed between the 
splint and leg, and reach from the knee to the upper border of the 

Fig. 445. 



Dapuytren's splint modified. 

malleolus. "With a roller bandage confine the splint to the leg above, 
and with another roller secure the foot by turns having the form of a 
figure 8, which will draw the foot in an opposite direction to the dis- 
placement, the lower thick end of the pad pressing against the tibia, 
acting as a fulcrum. 

Fiff 446. 




Dupuytren's apparatus for fractured fibula. 

The form of Dupuytren's splint is somewhat modified, as seen in 
Fig. 445, by having two retiring angles or notches at its lower ex- 
tremity, and two holes at the upper one for tapes to pass in fixing the 
pad to the splint. The difference of its application consists in passing 
the lower convolutions of the bandage around the ankle and notches. 

The apparatus should be removed in three or four weeks, and 
passive motion impressed upon the joint daily, aided by stimulating 
and oily frictions. 

Fracture of the Tarsal Boxes. — The astragalus and calcaneum 
are sometimes broken by crushing violence applied to the foot, but 
the former is most often broken by persons falling from a height 
alighting upon their feet, and the latter by great muscular action, as 
when a person falling makes violent efforts to save himself, or in 
jumping. 

The other tarsal bones are fractured by the foot being crushed by 
heavy objects. 

The line of fracture may pass through the astragalus in most any 
direction — antero-posteriorly, horizontally, or transversely. In the os 
calcis it is seated usually in the neck of the bone, or sometimes be- 
neath the astragalus. 

Malgaigne has drawn attention to a species of fracture occurring in 



491 



SPECIAL FRACTURES 



these two bones attended with comminution and impaction of the upper 
fragment into the lower, causing a separation of the malleoli and an 
increased breadth of the foot. 

From the close connection of the tarsus by ligaments there can 
scarcely occur any displacement of the fragments except in the calca- 
neum, when the fracture is seated posteriorly to the lateral ligaments 
between them and the insertion of the tendo-Achillis, in which in- 
stance the posterior fragment will be drawn upwards. 

Symptoms. — The parts will generally be found much swollen and 
painful, the patient cannot stand upon the foot, and sometimes obscure 
crepitus may be elicited by rubbing the fragments together. If the 
tuberosity of the os calcis is broken off the connection of the gastroc- 
nemius will draw the detached piece upwards, and the heel will be 
shortened. 

Treatment — The mechanical requirements in fracture of the tarsus 
are few ; the foot must be placed upon a pillow, and inflammatory 
action combated by suitable remedies. The displaced tuberosity of 
the os calcis may be drawn ; the leg bent upon the thigh and the foot 
extended to relax the gastrocnemius muscles, and the slipper of Mon* 
roe, described at page 495, applied to retain this position, or the appara- 
tus of Mr. Lonsdale, which consists of a footboard 
Fig. 447. somewhat shorter than the sole, to the distal ex- 

tremity of which the end of a shoe is nailed to re- 
ceive the toes ; the proximal end has a ring attached 
with a long strap. The apparatus is applied in this 
manner : Draw the separated fragment down to the 
heel ; place a compress above, and confine it by a 
few turns of a roller ; now flex the leg, extend the 
foot, and put on the slipper; carry the strap over 
the point of the heel up the back of the leg to the 
inferior part of the thigh, where it is confined by 
turns of a roller bandage, and reflected upon itself 
to have a few more turns applied, when the dressing 
is complete (Fig. 447). 

Fracture of the Metatarsal Bones. — These 
bones can only be fractured by the application of 
crushing violence; there is usually no displacement 
of the fragments from their close connection with 
one another. Sometimes, however, the lower frag- 
ments have been found depressed backwards from 
the force of the injury causing the fracture. 
Lonsdale's apparatus. Treatment.— If. any displacement should exist it 

must be corrected by pressure with the finger ; 
then support the foot upon a pillow, and combat local inflammation. 
If the fragments show any disposition to slip away from the natural 
position in which they have been placed, a splint with appropriate 
compresses may be applied to the sole of the foot and secured with a 
roller bandage. 

Fracture of the Phalanges of the Toes. — The phalanges are 
broken by heavy bodies falling upon them, and the injury is such as 




FRACTURE OF THE PHALANGES OF THE TOES. 



495 



Fig. 448. 



often to demand the removal of the toes with the knife. In fracture 

of the phalanges of the great toe the irritation is such at times as to 

cause inflammation along the course of 

the lymphatics to the groin. If a splint 

is deemed necessary, one covering the 

whole sole of the foot, made of wood, 

binder's board, or gutta percha, may be 

employed, to which the toes can be bound 

by a narrow roller. 

Rupture of the Tendo-Achillis. — 
This injury results always from muscular 
action occurring while persons are in the 
act of jumping. 

The patient feels a crack about the 
ankle, and finds himself unable to extend 
the foot ; with the fingers an interval may 
be felt between the separated ends of the 
tendon. 

Treatment. — The treatment consists in 
bringing the ends of the tendon in apposi- 
tion, and retaining them until union takes 
place between them. This is accomplished 
by position — the leg is flexed upon the 
thigh, and the foot extended upon the leg ; 
the slipper of Monroe (Fig. 448) may be 
then applied in this manner : Put on the 
patient's foot an ordinary slipper having 
a strong cord attached to its heel; around 
the lower part of the thigh buckle a broad strap also, with a cord; now 
tie the two cords together, and the apparatus is completed (Fig. 448). 
The anterior ankle splint of Monroe and the apparatus of J. L. Petit 
are also excellent contrivances for maintaining the leg in the proper 
position. 




Apparatus for ruptured tendo-Achiilis. 






PART IV. 

DISLOCATIONS: THEIR REDUCTION, DRESSINGS, AND 

APPARATUS. 



CHAPTER I. 

SPRAINS OR STRAINS. 

The articulations are liable to be violently twisted, their joint 
surfaces separated, and the ligaments stretched, or even ruptured, 
without any permanent displacement of the bones entering into their 
composition; these injuries are popularly known as sprains or strains. 

The symptoms are sudden and often severe pain, not unfrequently 
accompanied with a feeling of faintness; stiffness, and difficulty in exe- 
cuting the natural motions of the joint, about which there is more or 
less swelling and ecchymosis from extravasation of the blood into the 
cellular tissue, tendinous sheaths, and bursas. This swelling, how- 
ever, may occur some, distance from the joint, over the junction of the 
muscular with the tendinous fibres, where laceration most frequently 
takes place when the muscles are forcibly stretched. 

Effusion of serum into the textures near the injured part, and an 
increased secretion of synovia into the cavity of the joint, may alter 
its contour in such a manner that, without a very careful examina- 
tion, the injury may be mistaken for a dislocation. 

The chief discriminating feature of a sprain is the absence of any 
displacement of the bony surfaces entering into the formation of the 
joint. 

Should the injury be very severe, to the foregoing local symptoms, 
especially when one of the larger joints, as the knee, is involved, 
great constitutional disturbance will be added ; which, together with 
acute local inflammation, may produce dangerous, if not fatal conse- 
quences. All the joints are liable to sprains, but not in an equal 
degree ; the ankle, wrist, and elbow being most frequently affected ; 
the knee and hip less so ; while they are rarely ever met with in the 
shoulder. The vertebral articulations, though so strong and so amply 
protected with large muscles, also suffer from sprains. 

It is the ginglymoid class of joints particularly which is most obnox- 
ious to these injuries ; and a comparison of their anatomical construction 
with that of the enarthrodial joints will readily explain why this is so. 
In the first place, the hinge- like articulations move but in two direc- 
tions, forwards and backwards ; in the second, they are bound together 



SPRAINS OR STRAINS. 497 

by short, strong, and thick ligaments, that yield very little to an 
extraneous force tending to separate the joint surfaces, and hence they 
are often torn; a circumstance enabling us also to account for the 
greater seriousness of these sprains than those of the enarthrodial or 
ball-and-socket joints, which have a greater range of motion, thinner, 
weaker, and more extensible ligaments — conditions that concur in 
conferring upon them a greater immunity from sprains and the lace- 
ration of the ligaments. 

Of all the joints, the ankle suffers most often from this sort of vio- 
lence, and the right ankle more frequently than the left in the propor- 
tion of three to one. 

The injuring force acting upon the ankle will, in a majority of 
cases (twelve to one), cant the foot inwards, and produce what Dupuy- 
tren called an external sprain. The cause of this difference is stated 
to be the obliquity of the superior surface of the astragalus, which is 
from above downwards, and from within outwards; favored also by 
the circumstance that abduction of the foot is more easy and extended 
than adduction. 

The spraining of the ankle by the movements of forced flexion or 
extension is more rare than by the lateral or twisting motions. Some- 
times portions of the bone are detached with the tendons and liga- 
ments, and add much to the seriousness and severity of a sprain. 

Often, perhaps, many serious diseases of the synovial membranes 
and cartilages may be traced to a violent or a badly-treated sprain ; 
and this will not cause surprise when the extent of some of these 
injuries is considered; the tendons, ligaments, cellular tissue, blood- 
vessels, nerves, muscles, and even the bone itself, participating to a 
greater or less extent in the mischief, according to the severity of the 
sprain and the state of the patient's constitution at the time of the 
injury. 

It not nnfrequently happens that even when the more serious 
symptoms have passed away, the swelling diminished, and some mo- 
bility restored to the joint, it still remains stiff and weak, and more 
than ever liable to sprains. When the knee is sprained by a fall or 
misstep, the violence is usually expended upon its internal lateral 
ligament, while the swelling will be found upon its external face. 

It occasionally happens that the fascia forming the sheaths of mus- 
cles and tendons is ruptured, and permits them to spring outwards 
through the aperture. This form of accident is especially observed 
in the quadriceps extensor of the thigh, the long head of the biceps, 
and in the extensor tendons of the fingers. 

Causes. — The causes of sprains are muscular contractions, falls, 
and violent or exaggerated motions of the joints, producing forced 
extension, flexion, lateral movements, or rotation. 

Prognosis. — Where these injuries are slight, patients readily re- 
cover from them ; although, even in these instances, in rheumatic 
subjects, persistent and serious symptoms often result. 

Severe sprains may produce paralysis, atrophy, muscular rigidity, 
and chronic arthritis, the latter sometimes demanding amputation. 

The greatest diligence should be exercised in making out a clear 
32 



498 SPRAINS OR STRAINS. 

diagnosis, before any plan of treatment is instituted. The manual 
examination must be thorough and at the same time gentle, that no 
unnecessary pain may be inflicted upon the patient. 

Sprains have been very frequently confounded with dislocations ; 
but proper attention to the diagnostic symptoms will generally pre- 
vent any such occurrence. It will be well to mention in this connec- 
tion, that the hip-joint may be severely sprained by the slipping of 
the foot outwards, causing forced abduction of the limb and stretching 
of the capsular ligament, which may lead the practitioner astray in 
supposing a dislocation downwards and forwards into the thyroid 
foramen, from the somewhat analogous character of the symptoms of 
the two injuries. 

Treatment. — In robust and plethoric patients, in whom the local 
inflammation and constitutional reaction are great, a moderate general 
bleeding may become necessary, but in most cases cupping or leeching 
will suffice. 

Cold may be applied to the joint by the India-rubber sack already 
spoken of, which will enable the surgeon to obtain a uniform tempera- 
ture of any degree. 

A still simpler plan is to immerse the injured part in a vessel of 
water of the desired temperature. For instance, if it is the ankle, the 
pail containing the water must be placed by the patient's bedside, near 
enough to permit his heel to rest upon its bottom, a large sponge being 
interposed to prevent hurtful pressure ; the thigh may be supported 
by pillows. 

Irrigation by means of the apparatus described at pages 87 and 91 
is also a good plan for obtaining the sedative influence of cold. 

In slight cases of sprains, an immersion of the part in cool water 
for forty- eight hours will often relieve the pain and swelling suffi- 
ciently to enable the patient to dispense with it ; in severer cases, to 
obtain any decided result an immersion of eight or ten days, or even 
longer, will be necessary. 

Cloths wrung out of cold water, or water mixed with alcohol and 
tincture of camphor, wrapped about the joints, have been recommended 
as a convenient method ; but the proper management of such a dress- 
ing is really difficult, for without the most assiduous attention on the 
part of the attendant inequalities of the temperature of the parts are 
sure to result in changing the cloths, and therefore frequent and inju- 
rious reactions must occur. 

Cold affusion, by directing a stream of water from a pitcher held 
five or six feet above the bed upon the joint, in the first or acute stage 
of a strain, will be likely to do more harm than good by the frequent 
reactions thereby produced ; but when the inflammatory symptoms 
have been controlled by appropriate remedies, cold affusion will con- 
tribute greatly to bring about a rapid convalescence. 

Should cold be found disagreeable to the patient's feelings, fomen- 
tations with solutions of acetate of lead and opium, hydrochlorate of 
ammonia and opium, or warm salt water, may be substituted for it. 

Poultices of scraped Irish potatoes, carrots, or hashed persil made 
with lead water, are the favorite remedies of some practitioners. 



SPRAINS OR STRAINS. 



499 



TThile the acute symptoms are passing away, the parts become 
discolored and pass through various shades of green, blue, purple, 
and yellow to the normal color of the skin. Any remaining stiffness, 
weakness, or swelling of the joints must be treated with stimulating 
applications, such as volatile liniment, Granville's lotion, and fish brine. 
Frictions and massage will likewise contribute to their removal. 

Paralysis of a limb resulting from a sprain will be benefited by 
electricity, galvanism, the counter-irritation of the heated hammer 
adverted to farther on, and repeated blistering. 

For some time after the injury it will be advisable to support the 
joint by elastic bandages. I sometimes find advantage accruing as 
regards comfort and facility in walking from the use of 
the apparatus seen in Fig. 449. It consists of an ordi- 
nary laced boot with two side stems attached to its sole 
and running up the limb to a point just below the knee, 
where they are connected together by a padded me- 
tallic strip which embraces this part of the leg; a spiral 
spring extends between one of the side rods and the sole 
of the boot, which by its elasticity brings the foot in a 
rectangular position again after it has been extended or 
flexed. 

It cannot be too forcibly impressed upon the mind of 
the student that all interference with the knife, with a 
view of giving issue to the effused blood, is highly 
reprehensible ; as such incisions cannot accomplish this 
object ; while, on the other hand, they would be likely 
to cause inflammation of the cellular tissue. Nature 
amply provides for the removal of the blood in due 
time by means of the absorbents everywhere present; 
while, it may be remarked, its temporary presence in the tissues will 
not be productive of any harm. 

Compression, after the acute symptoms have passed, by means of a 
proper bandage, will exercise a beneficial influence upon sprained 
joints. Baudens has recommended one for the ankle which is exceed- 
ingly efficient and elegant. It is applied in the following manner : 
first pad the depressions below the malleoli with cotton or tow, and 
over this lay three compresses, imbricating and crossing them over 
the instep ; then with a roller eight yards long and two inches wide 
inclose the ankle, beginning by placing its initial extremity upon the 
inner surface of the os calcis of the left foot (outer side for the right), 
as low down upon the point of the heel as possible, carry the cylinder 
obliquely across the dorsum of the foot to the root of the little toe, 
around the base of the toes to gain the inner border of the foot, then 
crossing the previous turn upon its dorsum go around the heel to the 
point of departure ; continue these turns in this manner until the foot 
and ankle are neatly covered in. The bandage being completed, apply 
over its surface, with a brush, a solution of starch ; in twenty-four 
hours it will be thoroughly dry. The limb should be kept quiet and 
in an elevated position from ten to thirty days according to the severity 
of the injury. For the knee, the middle part of the spiral bandage 




Shoe to assist in 
walking after 
dislocation. 



500 DISLOCATIONS IN GENEKAL. 

described at page 209 will, when starched in the same way, serve a 
good purpose in keeping the joint immovable, and making compression. 

Some constitutional treatment will be necessary in those persons 
who are of a gouty or rheumatic diathesis, or whose general health is 
shattered by long confinement ; the appropriate remedies are colchi- 
cum, iron, cod-liver oil, and alteratives. 

Although a slight sprain will get well under the use of tincture of 
arnica, spirits of camphor, or a mixture of laudanum and lead-water 
applied locally, while the patient is pursuing his ordinary occupation, 
yet it will always be the safest and surest plan to enjoin absolute rest 
for the injured limb a few days. 

With the starched bandage patients can take exercise upon a crutch, 
which will contribute greatly in maintaining their general health until 
the parts are sufficiently recovered to submit to passive exercise, and 
thus gradually resume their natural functions. 

This passive exercise should not be delayed too long ; otherwise the 
joint may become irreparably damaged by anchylosis. 



CHAPTEE II. 

DISLOCATIONS IN GENERAL. 

Nomenclatuee. — A dislocation or luxation is the permanent dis- 
placement of joint-surfaces from their normal relations with each 
other. 

When it results from external violence or muscular action, it is 
called a traumatic dislocation. 

If the displacement occurs from some morbid changes in the joint 
itself, as ulceration or caries of its articular surfaces, it is termed a 
'pathological dislocation; but, even in this case, muscular contraction or 
some slight external force is generally the immediate cause. 

Congenital dislocation is such as is met with in recently -born infants, 
having occurred during intra-uterine life. 

A complete dislocation is one where the joint surfaces have been 
completely separated from each other, and an incomplete, or partial 
dislocation, where they yet remain in apposition to some extent ; the 
latter variety occurring mostly in ginglymoid articulations. 

A single dislocation, as its name implies, affects but one joint, while 
in a double dislocation two corresponding joints upon opposite sides of 
the body suffer. 

In multiple dislocation two or more luxations occur, not thus corres- 
ponding; for instance, those of the ankle and wrist, shoulder and hip. 

The terms recent and old dislocations, although arbitrary, and of 
little value as mere expressions of lapse of time since the injury, yet 
they are of much practical importance when considered as indications 



FREQUENCY. 501 

of the pathological changes that always follow it, and upon the nature 
and extent of which the ease or difficulty of reduction depends. 

In a primitive dislocation the head of the displaced bone remains in 
the original situation in which it was first forced; in consecutive dislo- 
cation it abandons this position and seeks another, either in conse- 
quence of some peculiarity in the application of the violence, or from 
some diseased changes in the bones themselves. 

No dislocation can occur without some injury to the surrounding 
soft parts ; when this is moderate, or about the average amount, the 
luxation is technically said to be simple, while the term complicated 
indicates that it is accompanied with an unusual amount of contusion 
of the surrounding tissues,, tearing of ligamentous and muscular fibres, 
rupture of some bloodvessel or nerve, or with a wound. 

A compound dislocation is defined to be one where there is a com- 
munication established between the cavity of the joint and the exter- 
nal air. 

Malgaigne proposes the adoption of the term complex to imply that 
the luxation is accompanied with articular fracture. 

From the fact that all authors have not agreed as to which of the 
two bones comprising a joint should be considered as the displaced 
one, more or less confusion has arisen in consequence in designating 
the varieties of dislocation; and it was not until recently that the 
rule has been generally adopted to regard, in dislocations of the extre- 
mities, that bone displaced which is farther from the trunk ; and in dis- 
locations of the bones of the trunk, that one farthest from the cranium. 
The ankle-joint is, however, excepted from the rule without reason. 
The arbitrary use of such terms as downwards, upwards, forwards, back- 
wards, and their combinations to express the direction of a dislocated 
bone, has also caused more or less perplexity ; and, therefore, recent 
writers have abandoned them, and sought others more exact ; so that 
now appellations, based upon the anatomical relations assumed by the 
head of the luxated bone, are coming into general use ; for instance, 
instead of following Sir A. Cooper, and designating the four principal 
dislocations of the hip-joint as taking place upwards, backwards, for- 
wards, and downwards, surgeons prefer to imitate Malgaigne and 
Nekton, and adopt the anatomical terms iliac, ischiatic, ileo-pubic, 
and ischio-pubic to express them ; the latter is certainly the prefera- 
ble method. 

Frequency. — All the joints are liable to dislocation, but not in the 
same degree ; the enarthrodial articulations suffer more frequently than 
the arthrodial, ginglymoid, and the amphi-arthrodial, under which latter 
fall the hinge-like joints, and those characterized by gliding movements 
of the bones upon one another, as is observed in the carpus, tarsus, and 
the junctions between the vertebrae. The greater range of motion of 
the enarthrodial or ball-and-socket joints, coupled with the anatomical 
arrangement of their constituents — a shallow socket, limited contact 
between their opposing bony surfaces, and loose capsular ligament — 
is the principal cause of this relative greater frequency. For, under 
these conditions, there is a much greater chance of a dislocation upon 
the application of external force than where the joint surfaces are 



502 



DISLOCATIONS IN" GENERAL. 



broad, and bound together by strong and thick bands of ligamentous 
fibres which limit the extent of joint motion to the simple gliding of 
the bones upon each other, or to that yet more extended movement 
forwards and backwards of which the knee is the most perfect type. 

Besides these circumstances, the position of the bones will also have 
an important influence; as those most exposed will, cseteris paribus, be 
more liable to dislocation than the bones deeply seated or well pro- 
tected with soft parts. 

The operation of these influences is strikingly seen by reference to 
the following table of 488 cases, drawn up by Malgaigne : — 



f the shoulder . 


. 321 


Dislocation of the 


fingers 


. 7 


" hip . 


. 34 


« 


tt 


jaw . 


. 7 


" clavicle . 


. 33 


u 


u 


knee . 


. 7 


" elbow 


. 26 


« 


(( 


patella 


. 2 


" foot . 


. 20 


« 


(( 


spine . 


. 1 


" thumb 


. 17 











" wrist 


. 13 


Total 






. 488 



The comparative frequency of dislocation in the upper and lower 
extremities is in the ratio of seven to one. The facility with which 
the epiphyses separate from the shafts of long bones in youth, and 
the brittleness of the bones in the aged, render these two classes of 
persons more liable to fracture than to dislocation, which last is most 
frequently encountered among persons between thirty and sixty-five 
years of age. 

Causes. — The causes of dislocation are predisposing and exciting ; 
among the former may be ranked age, sex, the state of the general 
health, and the position of the joint surfaces at the time of the inflic- 
tion of the injury. 

As has already been stated, it is rare in childhood and old age, on 
account of the condition of the bones at these periods favoring fracture 
rather than dislocation. 

According to the interesting statistics of Malgaigne, males are more 
frequently affected than females in the proportion of seven to one ; 
this is probably owing, in a great measure, to the less exposure of 
females to mechanical violence in their daily avocations of life. 

Persons of relaxed habit of body, in general bad health, and who 
have suffered from rheumatism, gout, and syphilis, are liable to have 
their joints dislocated by a force which, were they in health, would 
not produce any permanent displacement. 

Great relaxation of the ligaments, or a large collection of synovia 
in a joint, may permit a complete dislocation without any rupture of 
the tissues in its neighborhood, or will even enable the person to effect 
it at his pleasure. 

Dr. Haynes, of Saratoga, New York, has reported a case of the 
kind in which a lad aged seven years was able to dislocate and reduce 
at will the knee, elbow, wrist, thumb, and fingers. 

Sir A. Cooper relates three other instances : one of a dancing-girl 
who could throw the patella upon the outer condyle of the femur, and 
in whom this had occurred when a child from violent exertion ; the 
second case was that of a lad who had been punished on board ship 



PATHOLOGICAL ANATOMY. 503 

by having his arm elevated and tied above his head while he stood 
upon a small projection upon the deck ; he could dislocate the shoul- 
der by merely elevating the arm to the head ; the last case occurred 
in a man fifty years old, who had had his hip dislocated, and was ever 
after that able to cause it to happen whenever he chose. 

The position of the articulating surfaces at the time of the applica- 
tion of the force will also have an important influence, inasmuch as in 
certain postures of the limbs the articular surfaces will not be in such 
close and extended contact as in others ; as, for instance, when the 
arm is abducted and elevated, the thigh flexed upon the body, the 
lower jaw depressed; or lastly, when a limb is in a restrained or 
twisted position. All of these circumstances will materially favor the 
production of a dislocation. 

The exciting or efficient causes are external violence and muscular 
action. The former acts either directly upon the joint, or indirectly 
upon it through the limb below, the latter mode being the most fre- 
quent in causing dislocation. We see the influence of indirect vio- 
lence exemplified in these cases of luxation of the hip and shoulder 
produced by falls from a height upon the feet and hands. If, instead 
of alighting upon the feet and hands, the knees and elbows come first 
in contact with the ground, the force acts in a much more efficient 
manner, for the reason that the thigh and arm, being inflexible levers, 
transmit it undecompounded and undiminished to the joint above. 
The bending of a limb at an intervening articulation during the appli- 
cation of violence, will often prevent the occurrence of a dislocation. 

Mere muscular action will sometimes effect a dislocation without 
the aid of external violence, and is due, in a great measure, to some 
accidental position assumed by a limb, destroying for the time the 
antagonism of the muscles inserted into the bone, one set of which 
thus acting more energetically than the opposing set, will drag the 
head of the bone from its socket into an abnormal position. Disloca- 
tion from muscular action has been observed most frequently in the 
temporo-maxillary and scapulo-humeral articulations, though cases 
are recorded in which the hip and patella have been luxated from the 
same cause. 

Organic disease of the cartilages and ligaments from ulceration and 
caries will favor the occurrence of dislocation from muscular action. 

Pathological Anatomy. — The pathological changes consecutive 
on dislocation are exceedingly interesting and important, and ought 
to be carefully studied by every person liable to be called upon to 
reduce a luxation, as it is upon the extent of these that the practica- 
bility of restoring the displaced bone depends after the lapse of some 
time. When a recent luxation is examined, the head of the bone will 
be found removed from its socket to a greater or less distance, accord- 
ing to the nature and degree of the violence that caused the displace- 
ment, and the character of the tissues surrounding the joint. 

The ligaments will be ruptured in various degrees, from a mere slit 
just large enough to permit the head of the bone to escape from its 
capsule, to a complete laceration and separation, so that the shreds 
and remnants hang from the margins of the joint, or in front of its 



504 DISLOCATIONS IN GENEKAL. 

socket, in such a manner as to interpose themselves between it and 
the head of the bone ; the cartilages may be fissured, or even torn 
from the bone; and in complicated cases the nerves and bloodvessels 
sometimes participate, and are violently stretched or even lacerated, 
producing in the first instance paralysis of the limb below the dislo- 
cated joint, and in the other, hemorrhage into the socket and sur- 
rounding tissues. 

The muscles about the injured articulation are usually more or less 
violently extended, contused, and the fibres sometimes torn through ; 
generally tensely stretched upon one side of the joint ; and relaxed 
upon the other. 

Bones are, in general, more disposed to be luxated in certain direc- 
tions than in others, according to the anatomical arrangement of the 
joints ; thus the bones of the forearm at the elbow are more com- 
monly displaced backwards, next laterally, and rarely forwards from 
the opposition offered by the olecranon hooking around the humeral 
condyles. 

According to Malgaigne, the direction of the displacement is deter- 
mined by the point and extent of the tearing of the capsular ligament. 

When the bones are promptly restored to their natural relation at 
the joint, the functions of the limb will be again established, and the 
injury to the soft tissues repaired more or less perfectly, according to 
the amount and nature of the injury. 

If this restoration is not accomplished within a few weeks, the 
inflammation which has begun in the parts will be attended with the 
effusion of plastic lymph about the joint, which will mat and glue the 
adjacent tissues into one mass; and in the progress of the case the 
cellular tissue becomes dense and thick, the neighboring muscles 
undergo fatty degeneration ; the head of the bone, reposing upon some 
muscle, tendon, or bone, contracts new and intimate relations with 
them by the formation of a new socket and capsular ligament, com- 
municating or not with the old capsule, according as its rupture was 
originally complete or not. An imperfectly organized synovial mem- 
brane will also be formed upon the inner surface of the new joint. 
The old socket participates in these changes, and is gradually effaced 
by its margins being levelled with the adjoining surface. 

Symptoms. — The symptoms of dislocation are, pain, alteration in the 
figure of the joint, deviation of the axis of the limb from a right line, 
and an alteration in its length ; contusion and ecchymosis, immobility 
and absence of crepitus. 

At the moment of the infliction of the injury the patient may be 
conscious of something having given way or altered its position in a 
joint, described by some as a " crack" or " noise ;" pain is felt in the 
part, which varies in its intensity and character, but is generally severe 
(nervous and irritable persons suffering the most), and lasts for a few 
days or even weeks. It is caused by the stretching and rupture of 
the nervous filaments about the joint, and is aggravated by handling 
the limb, and also when inflammatory action supervenes. Should the 
principal nerve be pressed upon by the displaced bone, the extremity 
will tingle and feel numb. 



SYMPTOMS. 505 

The alteration in the normal contour of the joints is an important 
character in the symptomatology of dislocation. It is due to two 
causes : first, to the changed position of the extremities of the bones 
entering into their composition ; second, to effusion of blood from the 
ruptured vessels, and inflammatory exudations. 

From these two causes will proceed those alterations in the normal 
positions and relations of the bony prominences and depressions which 
are naturally present and recognizable about the joints in their healthy 
state. 

If the swelling results from effused blood, it will occur immediately 
after the injury, while that from inflammatory action will appear, pari 
passu, with the increase of the inflammation. 

An alteration in the axis of the limb will be observed, which, in- 
stead of representing a straight line, will be broken into two sections, 
placed at a greater or less angle with each other, according to the 
inclination of the displaced bone with that bone to which it is nor- 
mally connected. 

The limb will also generally be found more or less forcibly rotated 
inwards or outwards, and sometimes stands off from the body at an 
angle. 

A dislocated limb will commonly undergo some change in its 
length ; though in the ginglymoid joints, where from the breadth of 
the articular surfaces a partial displacement only most always occurs, 
no change of length w r ill be observed. In most of the other joints 
some shortening takes place ; yet there are some exceptions, the most 
notable of which are dislocation of the humerus downwards, and of 
the femur into the thyroid foramen ; in both of these cases the limb 
will be lengthened half an inch or more. 

Contusions and ecchymoses about the injured joint or elsewhere 
should not be forgotten or overlooked when considering the nature of 
this injury, and particularly the modus operandi of the force produc- 
ing it. 

Immobility is one of the most valuable symptoms of dislocations 
from the fact that the joints have an important agency in the functions 
of the limbs, so that any displacement of their constituent elements 
will bring about a speedy abolition of motion. This is seen in dislo- 
cation of the shoulder and hip where the patient cannot voluntarily 
move the affected arm or walk upon the leg without excruciating pain. 
These restrained motions will also be manifest when the surgeon 
manipulates with the limb, which always causes acute pain. 

When the ligaments are thoroughly lacerated, there may be in the 
beginning, before the muscles are spasmodically contracted, preter- 
natural motion, so that a fracture might be suspected where it really 
does not exist. 

Immobility is due to several causes ; the principal of which are 
muscular contraction, interlocking of the head of the displaced bone, 
as sometimes happens in dislocation of the elbow, the presence of some 
osseous prominence as seen in the hip, in which the projecting lip of 
the acetabulum will frequently oppose itself to any movement of the 
head of the femur, and lastly, ligamentous bands will cause it. It will 



506 DISLOCATIONS IN GENERAL. 

generally be found, however, that two or more of these causes will be 
in operation in the same case at the same time. 

Crepitus is another symptom sometimes connected with dislocation, 
and results probably from the rubbing together of surfaces roughened 
by effused lymph. It is never observed until after the inflammatory 
process has been established ; which fact gives strong support to the 
above explanation. Malgaigne attributes the crepitus to the rubbing 
of the head of the displaced bone against a bony surface denuded of 
its periosteum. However, the subdued dull sound produced by the 
rubbing together of roughened cartilages or synovial membranes is 
quite distinct from the sharp, quick, and dry sound proceeding from 
the friction of the extremities of a broken bone ; and which, although 
not present in all cases of fracture, will yet be observed, when it is 
present, from the first moment of the injury. Lastly, if the surgeon 
seizes the dislocated joint in both his hands, when there is no great 
swelling, and directs an assistant to move the limb cautiously, he can 
generally recognize the head of the bone in its new position. 

Diagnosis. — It should always be borne in mind that although in 
general a dislocation may be accurately diagnosed from those injuries 
and diseases which resemble it in their symptoms, yet there have been 
cases that have defied the skill of the most accomplished surgeons. 

In their early stages, dislocations may be confounded with fractures 
near the joints, sprains and contusions; and in their later, or when 
the bone has remained unreduced for a long period, they have been 
simulated by anchylosis, white swelling, deformed callus, and exostosis. 
By a close attention to the symptoms we have already laid down, a 
dislocation, when seen early, may always be recognized. If the joint 
is much swollen and the bony prominences cannot be felt, accurate 
measurements of the limb should be made with a tape-measure, and 
comparisons made with the healthy limb. A knowledge of the manner 
in which the injury was produced may also throw some light on the 
diagnosis. The limb should be manipulated to ascertain the nature 
and extent of the movements possessed by it. M. Malgaigne recom- 
mends the use of a slim needle, which should be thrust through the 
tissues down to the bony surfaces, to ascertain with precision the rela- 
tions of the prominences and depressions of the latter. 

Prognosis. — In simple dislocation, when the head of the bone is 
promptly returned to its socket, and no great injury has been inflicted 
upon the limb, the joint is usually speedily restored to its normal 
integrity in between three and five weeks; so that the patient can use 
the limb without pain or inconvenience, although some disposition to 
subsequent displacement may yet remain. 

Compound and complicated dislocations are more serious, both as 
regards danger to life and the ultimate usefulness of the limb. They 
usually result from a greater amount of violence than simple disloca- 
tion, and are hence dangerous in proportion to its amount, to the 
extent of the injury, and the importance of the parts damaged. 

The joints are more frequently left in a weakened and altered con- 
dition, disposing them both to a recurrence of the dislocation and to 
subsequent inflammatory and ulcerative changes, which sometimes 
require amputation ultimately, to save the patient's life. 



TREATMENT. 



507 



Treatment. — The treatment of dislocations presents four indica- 
tions : 1st, to restore the bone to its normal position ; 2d, to facilitate 
the restoration of the damaged parts ; 3d, to re-establish the natural 
motions of the articulations ; 4th ; to combat any complications that 
may occur. 

1. To restore the hone to its normal position. — There are two methods 
by which this may be accomplished: first, by manipulations; and 
second, by making extension and counter-extension. 

The first plan, or that by manipulation, consists in changing the 
position of the displaced bone in such a manner, by the hands of the 
surgeon, that those muscles which oppose the reduction are relaxed, 
while its head is thrown, by making a lever of the bone, near the 
socket, when the contraction of the muscles themselves will draw it 
with a "snap" into its natural position, and the reduction is accom- 
plished. The details of the process, as applicable to individual disloca- 
tions, will be discussed under appropriate headings. Simple pressure 
with the fingers will often succeed in replacing the bones when only 
partially luxated. 

The second process, or that by extension and counter-extension, is 
effected by the natural forces of the surgeon, aided by assistants if 
additional power is requisite, or by the application of certain mecha- 
nical appliances. The extension should be gradually made, with the 
least possible pain and inconvenience to the patient; the part to which 
the extending lac is applied must be protected by being covered with 
a wet roller, to protect the skin and prevent its slipping. In putting 
on this roller, the integuments may be drawn up a little, so that the 
traction will not stretch the skin painfully before the extending force 
is brought to bear upon the parts beneath. 



Fig. 450. 



Fig. 451. 




The clove-hitch. 



A secure way of fastening the extending lac 
over the wet roller is with the clove-hitch ; 
its two ends are then knotted so as to form a 
loop, which affords the surgeon a good pur- 
chase if he wishes to use his hands; or it may 
be placed over the hooks of the pulleys. 

Any amount of power can be obtained with 
the pulleys (Fig. 452); but they are not now 




Application of the clove-hitch. 



508 



DISLOCATIONS IN GENEEAL. 



much employed since the introduction of the anaesthetics, which so 
thoroughly relax the muscles that with the hands alone almost all recent 
cases of dislocation may be promptly reduced. If it is necessary, 
however, to have recourse to them, the patient should be placed in a 
recumbent posture, or permitted to sit up, as found most convenient, 
and the extending lac applied as we have above described ; or a broad 
leather belt with a loop attached may be buckled around the limb, to 
which one of the hooks of the pulleys is fastened, the other hook 

Fig. 452. 





Pulleys and iron ring to which on.e of their hooks is fastened. 

being placed in the iron ring screwed into the wall. The counter- 
extending band, formed of a sheet or a broad piece of strong muslin, 
is arranged in an opposite direction to the pulleys, and its two ends 
secured to a point in the wall or floor in the line of the direction of 

Fig. 453. 




Application of the pulleys. 

traction. Fig. 237 illustrates the mode of reducing dislocation of the 
hip by the pulleys. 

Dr. Fanestock, of Pittsburg, Pa., instead of the pulleys has recom- 
mended as a good substitute the rope windlass, which is thus described 
by Dr. Gilbert: "Place the patient, and adjust the extending and 
counter-extending bands as for the pulleys; then procure an ordinary 
bed-cord, or a wash-line, tie the ends together and again double it 
upon itself, pass it through the extending tapes or towels, doubling 



TREATMENT, 



509 



the whole once more, and fasten the distal end, consisting of four loops 
of a rope, to a window-sill, door-sill, or staple, so that the cords are 
drawn moderately tight ; finally, pass a stick through the centre of the 
double rope, then, by revolving the stick as an axis, or double lever, 

Fig. 454. 




the power is produced pre- 
cisely as it should be in such 
cases, viz., slowly, steadily, 
and continuously." 

The same steady and con- 
tinuous power may also be 
obtained by another simple 
contrivance, the dislocation 
tourniquet of Mr. Bloxham, 
of London. This instrument 
resembles the ordinary tour- 
niquet of Petit, and acts in a 
similar manner; by turning 
the screw the extending cord, 
which is fixed between the 
band encircling the limb and 
a staple in the wall, is gra- 
dually shortened by almost 
imperceptible increments of 
power until the bone is drawn 
into its natural position. 

Mayor, Sedillot, and other 
European surgeons have de- 
vised special instruments for 
the purpose of making exten- 
sion; but those already de- 
scribed will answer every pur- 
pose as well as the most com- 
plex machines. 



Fig. 455. 




510 DISLOCATIONS IN GENERAL. 

The surgical adjuster of Dr. Jar vis is also a powerful instrument, 
and has been employed by its inventor successfully in many cases of 
old luxations. 

Another mode of applying power to a dislocated limb is by con- 
tinuous elastic extension, which is certainly destined in future to play 
an important role in the treatment of this class of injuries, especially 
in " old" and congenital luxations. As my experience in its use has 
been limited to two cases of old dislocation, I am at present illy pre- 
pared to decide upon its merits from personal observation, yet a con- 
sideration of its mode of action, and a knowledge of its effects in other 
surgical injuries, in which the contraction of the muscles plays an 
important agency, induce me unhesitatingly to accept the present 
success of elastic extension in the reduction of old and congenital 
dislocations as a harbinger of more brilliant triumphs in this field of 
surgical therapeutics. 

Much credit is due to Dr. Henry G. Davis, of New York, for the 
development of this important principle. He remarks, " that by this 
plan of elongating the soft tissues, all dislocations, whether recent or of 
many years' standing; all fractures, all deformities that are dependent 
upon the soft tissues are entirely within our control. These soft tis- 
sues can be elongated or shortened as we please. Ligaments that are 
inextensible, that are designedly made unyielding, are no exception to 

this rule We have reduced dislocated hips at all periods of 

time, from the recent up to that of fourteen years' standing, and, in 
the latter case, restored a club-foot on the same limb at the same time. 

"So far as the certainty of a reduction is affected, a luxation of 
twenty years' standing is upon the same footing as one of twenty days. 
The principal difference is in the length of time required to accom- 
plish it. We do not say there is the same certainty of the joints being 
equally useful in both cases, only that each can with certainty be re- 
stored to its original locality. 

"All danger of injury to the bloodvessels or nerves by this mode 
of preparing the parts will be avoided, as they elongate with the other 
soft tissues. This is of the highest importance ; for it is well known 
that in old dislocations of the humerus attempts at reduction have in 
some instances been most disastrous." 

The mode of applying the elastic cords will, of course, vary with 
the position of injured joints ; the general plan being to apply adhe- 
sive strips to the limb below, to which the elastic cords may be 
attached, the balance of the arrangement will readily suggest itself to 
the surgeon as the requirements of the various cases are presented to 
his mind. 

2. For fulfilling the second indication, that is, to facilitate the restora- 
tion of the damaged tissues. — The joint should be kept quiet, and in 
such a position that the dislocation is not likely to recur; during 
the time that the torn ligaments are healing a suitable amount of sup- 
port must be given to the joint. 

3. The third indication, to re-establish the natural motions of the arti- 
culation, demands that, as soon as the inflammatory symptoms have 
abated, passive motion must be had recourse to, and persevered in 



DISLOCATIONS OF THE HEAD AND TRUNK, 



511 



daily until the functions of the joint are restored ; which will seldom 
occur inside of several months. 

Absorption of the effused fluids will be materially hastened by in- 
frictions of volatile or other stimulating liniments, the cold douche, 
friction, and the massage. 

4. The fourth indication, to combat any complications that may occur, 
requires the employment of antiphlogistics, general and local, to con- 
trol the inflammation, which is developed in the joint in almost all 
cases. 

The best local applications are evaporating lotions of alcohol and 
water, and solution of acetate of lead, with the tincture of opium. 

If the case should be complicated, with the laceration of a nerve, or 
an artery (in the latter instance giving rise to aneurism) the bone 
should be reduced in the usual manner, and the injured nerve and 
aneurism subsequently treated as though they were primary affections. 



CHAPTER III. 

PARTICULAR DISLOCATIONS. 



SECTION I. 

DISLOCATIONS OF THE HEAD AND TRUNK. 

Dislocation of the Infekioe Maxilla. — Dislocation of the 
inferior maxilla takes place in two modes : First, both condyles are 
displaced from the glenoid fossae — bilateral or double dislocation; 
second, one condyle only is so 

displaced — unilateral or single Fig. 456. 

dislocation. 

The former variety occurs most 
frequently in the proportion of 
three to one. 

An outward displacement of 
one of the condyles has been 
observed ; but this can only hap- 
pen when accompanied with a 
fracture upon the opposite side. 
Dislocation of the lower jaw is 
always complete ; those cases de- 
scribed as subluxations appear 
to be nothing more than the 
catching of the head of the eoro- 
noid process against the anterior border of the inter-articular cartilage. 

Causes. — It arises from two sources, viz., muscular action and ex-> 
ternal force, the former being much more frequent than the latter. 




Double dislocation of the lower jaw. 



512 PAETICULAE DISLOCATIONS. 






According to Malgaigne, of 40 cases of this injury 25 resulted from 
muscular action, viz., from gaping, 15 ; from convulsions, 5 ; from 
vomiting, 4; from rage, 1; and 15 from external causes, viz., from 
extracting teeth, 9 ; from thrusting large objects into the mouth forci- 
bly, 6. Berard saw a case of unilateral displacement resulting from 
force applied at the left angle of the jaw from behind forwards. He 
thinks it probable that the chin may have been depressed to some 
extent at the time of the reception of the injury. Cases are also 
reported where the dislocation resulted from excessive salivation and 
violent gesticulation. 

In the majority of cases dislocation happens in adults between 
the ages of twenty and thirty years, though Malgaigne and ISTelaton 
have observed it in an aged subject, and in one but five years of age. 

This peculiar exemption in infancy and in old age is ascribed by 
Nekton, who has made special researches into this subject, to the fact 
that at the former period of life the coronoid apophysis is too short, 
and in the latter too much inclined backwards for it to reach the 
position it always assumes in dislocation, that is, against the inferior 
angle of the malar bone outside of the tubercle formed by its j unction 
with the superior maxillary. 

In order to understand the mechanism of the dislocation, it will be 
well to remember that the temporo-maxillary articulation is provided 
with a capsular ligament divided into two cavities by an inter-articular 
cartilage, each lined by its own proper serous membrane; the ex- 
ternal lateral ligament passes from the tubercle of the zygoma to the 
external surface of the neck of the lower jaw; the internal extends 
between the spinous process of the sphenoid bone to the margins of 
the dental foramen ; and therefore has no connection with the joint. 
The masseter, temporalis, and internal pterygoid muscles draw the 
lower jaw upwards and forwards against the upper ; the genio-glossus, 
genio-hyo-glossus, mylo-hyoid, and digastricus, depress the chin, while 
the external pterygoid and a few fibres of the masseter muscle bring 
it forwards. This anatomical arrangement will permit the condyles 
to slip forwards upon the transverse apophysis of the temporal bone 
when the mouth is widely opened, and to regain their position in the 
glenoid fossae when it is shut. Now if when it is in the former 
position the chin be still further depressed by muscular action, the 
condyles will be displaced forwards by the combined efforts of the 
external pterygoid and a few of the fibres of the masseter. Instead 
of the muscular action, if a violent blow be inflicted upon the chin 
which forcibly depresses it, the necks of the condyles will be brought 
more in a parallel line with the direction in which the fibres of the 
internal pterygoid and the masseter act ; then, instead of elevating the 
jaw by making a fulcrum of the condyles at the glenoid cavities, 
which always happens when the necks of the condyles are in an 
oblique position to these fibres, these muscles will draw the condyles 
into an abnormal position forwards. 

The mechanism of unilateral dislocation is the same ; the condyle 
which is not displaced will be rotated in the glenoid cavity, while the 



DISLOCATIONS OF THE HEAD AND TRUNK. 



513 




Dislocation of inferior maxilla. 



opposite one will take its ordinary Fi S- 457 - 

position. 

Symptoms. — The symptoms in re- 
cent cases of dislocation of the infe- 
rior maxilla are quite characteristic. 
(Fig. 457.) The chin is depressed and 
prominent, the mouth widely opened, 
the lower teeth project beyond the 
upper, so that the whole expression 
of the face is repulsive ; the saliva 
drips from the mouth, and articula- 
tion and deglutition are impossible, 
or performed with difficulty and pain. 
The jaw is immovable and painful 
from the pressure upon the temporal 
nerves ; the temples and cheeks are 
flattened and apparently elongated ; 
there is a prominence over the con- 
dyles, and between them and the 
meatus a depression with the skin 
tensely stretched across it. 

In rare cases the symptoms are not so prominent, and one is related 
in which the injury was not discovered, and the jaw remained perma- 
nently unreduced. In an instance of this kind, the jaws gradually 
approximate each other so that the patient can masticate his food, 
and articulate with little difficulty ; the saliva will cease to escape 
from the mouth, while the face will assume a tolerable appearance, 
although the chin will ever remain a little advanced. 

In unilateral luxation the chin will be generally found turned to 
the side opposite that on which the condyle is displaced ; but one 
depression will be observed in front of the ear ; the mouth will be 
less widely opened, and speech and deglutition interfered with in a 
less degree. 

Prognosis. — In recent cases the reduction is always easy, and the 
jaw will be restored to the full enjoyment of its functions. More dif- 
ficulty will be encountered in those of longer standing. Stromeyer 
reduced a dislocation of thirty-five days' standing, and Donava one of 
ninety days. To facilitate the operation in such instances it has 
been proposed to divide the masseter and internal pterygoid muscles 
subcutaneously. 

Treatment. — The indications of treatment are, to reduce the disloca- 
tion and to prevent subsequent displacements, to which there is 
always a tendency for some time afterwards. 

To accomplish the former object many plans have been suggested. 
The common one is to seat the patient upon the floor or a low stool ; 
the surgeon, standing in front of him, places his two thumbs, pre- 
viously wrapped with a bandage to protect them from being pinched 
between the teeth when the jaws come together, upon the molars, 
while the other fingers grasp the jaw, and presses downwards to dis- 
engage the condyles ; then, with a sudden movement, he elevates the 
33 



514 PARTICULAR DISLOCATIONS. 

chin, and the reduction is accomplished, generally with an audible 
snap. 

Sir A.Cooper introduced between the molars little wooden wedges, 
or the handle of a knife or fork; and while an assistant held them in 
position, he placed himself behind the patient, and dragged the chin 
upwards by means of a sling placed beneath it. 

Eavaton simply elevated the chin, making a fulcrum of the molar 
teeth. 

J. L. Petit describes a method that was pursued by some surgeons, 
consisting in striking a strong blow with the fist upon the under sur- 
face of the chin, in some of the cases a piece of wood having been 
previously interposed between the jaws. 

Nelaton recommends the thumbs to be introduced into the patient's 
mouth, and pressure be made upon the coronoid apophysis directly 
backwards, the other fingers taking a point oVappui upon the mastoid 
processes ; this pressure may even be made externally beneath the 
malar bone. 

Stromeyer used a specially constructed instrument, provided with 
forked branches fitting the dental arches above and below, and strong 
handles. 

For fulfilling the second indication, that of preventing the disloca- 
tion recurring, a sling-bandage should be applied to the jaw to main- 
tain it at rest for a week or ten days, then exercise it gently, that 
anchylosis may not take place ; the patient should confine himself 
to fluid or pap-like food for several days. 

Sir A. Cooper has described a condition which he designates as 
subluxation of the jaw; but from the experiments of Nelaton it would 
seem that the eminentia articularis does not offer any obstacle to the 
return of the condyle to the glenoid cavity, after the mouth has 
been widely opened, and hence there is nothing short of a complete 
dislocation. The condition alluded to occurs particularly in scrofu- 
lous and weakly people, whose tissues and ligaments are relaxed, and 
those about the temporo-maxillary articulation perhaps participating, 
may allow greater play to the inter-articular cartilage, enabling it to 
slip behind the condyle, and thus arrest the motion of the jaw sud- 
denly. This happens while the patient is eating or speaking; the 
mouth remains half open, the chin slightly advanced forward; and he 
has a sensation as if the condyle had slipped from its place, and feels 
pain upon the injured side. 

The malposition of the cartilage happens especially in delicate 
females, and is much benefited, and even cured, by tonic medication. 
The cartilage will easily slip into place by slight lateral movements of 
the jaw, or with the hand drawing the chin downwards and forwards. 

Dislocation of the Yertebb.^. — The vertebras are so strongly 
bound together by ligaments, and their articular surfaces so broad, 
that they are rarely found dislocated; indeed, some surgeons have 
doubted the possibility of it unless associated with fracture. There 
are, however, on record well-authenticated cases occurring in the cer- 
vical region, where the vertebras enjoy a much greater range of 
motion than in the other portions of the spine ; yet even here, fracture 



DISLOCATION OF THE VERTEBRAE. 515 

generally accompanies the dislocation. Luxation of the occipito- 
atloid articulation will be followed either by immediate death, or 
occurring within a very short period. 

From the greater range of motion in the atlo-axoid articulation 
it will be found to suffer more frequently than the preceding joint 
from dislocation. 

It is produced by falls from a height upon the head, violent blows 
upon the nape of the neck, and forced flexion of the head upon the 
chest. It has also been known to occur in children by raising them 
from the ground by the head. 

The transverse ligament of the atlas is either ruptured, or the odon- 
toid process slips beneath its lower border and is thrown against the 
spinal cord. 

The five lower cervical vertebrae may be dislocated forwards or 
backwards, the dislocation being complete or incomplete according as 
the articulating processes are wholly or partially separated from each 
other. If these are equally advanced, the luxation is bilateral, and 
unilateral when only one process is thrown forward, while the other 
retains its connection. Complete dislocation usually terminates fatally 
in a day or two, while incomplete and unilateral dislocation may lin- 
ger on some time longer, from four to six weeks. 

The dorsal vertebras are most commonly displaced posteriorly, the 
fifth, eleventh, and twelfth pieces being those most usually observed 
to suffer ; and the dislocation is almost invariably associated with frac- 
ture of their bodies and processes. 

Treatment. — The correct diagnosis of a dislocation of a vertebra is 
extremely difficult in most cases ; and this fact, perhaps, has deterred 
most surgeons from any active interference in this class of injuries of 
the spine. In several instances, however, where the dislocation has 
been seated in the cervical vertebrae, it has been recognized and suc- 
cessfully reduced. Mr. Erichsen says he has seen unilateral disloca- 
tion of the cervical vertebrae reduced by the surgeon placing his knees 
against the patient's shoulders, drawing on the head, and then turning 
it into position, the return being effected with a distinct snap. 

In Dr. Ayres' case of dislocation of the fifth cervical vertebra, 
counter-extension was made by placing two folded sheets obliquely 
across the shoulders properly secured, and extension by the hands of 
the surgeon, one being placed under the chin and the other over the 
occiput ; the traction being made first in the direction in which the 
head was thrown, or directly backwards, and then upwards. The 
patient had been thoroughly anaesthetized before the manipulations 
were commenced, and the bones were distinctly felt to slip into their 
places. 

Dr. Graves, of New Hampshire, reported a case of dislocation of the 
last dorsal vertebra successfully reduced by extension and counter- 
extension from the armpits and hips ; the patient was placed upon his 
face, and chloroform administered until he was completely under its 
influence. 

These cases will serve to illustrate the general method of procedure 
in dislocation of the vertebrae. 



516 PARTICULAR DISLOCATIONS. 

Dislocation of the Sternum. — This dislocation, which is very 
rare, occurs at the junction of the first with the second piece of the 
sternum. In early life these pieces are connected together by carti- 
lage and two ligaments, anterior and posterior ; in rare cases a true 
arthrodial joint is formed. 

The form of displacement which has been observed in the ten recorded 
cases of this injury, consists in the lower extremity of the manu- 
brium being depressed below the level of the body of the sternum. 

Causes.— Direct violence upon the sternum, as from a heavy blow 
with a club, and falls from a height upon the head and nates or lower 
extremities. The mechanism of the dislocation from the two latter 
causes is explained in this manner. When a person falls upon the 
head the weight of the body forces the chin violently against the 
sternum and depresses the manubrium. The same result will follow 
if the person alights upon the nates ; the neck will be violently flexed 
throwing the chin against the chest. 

Symptoms. — The symptoms of this injury are — pain over the ster- 
num, increased by pressure and the respiratory movements ; when the 
finger is passed from the top of the sternum downwards it will en- 
counter the projection formed by the upper extremity of its body. 

Prognosis. — Dislocation of the sternum is always a serious injury, 
being accompanied in the majority of cases with dangerous lesions of 
the organs of the thoracic and cerebro-spinal cavities. 

Treatment. — The efforts of the surgeon will generally be confined to 
combating the inflammatory complications as they arise; while if it 
should be deemed prudent to attempt the reduction in consequence of 
the pressure of the displaced bone upon the parts beneath, it may be 
accomplished by making strong pressure upon the dorsal region from 
behind forwards, counter-pressure being established at the same time 
over the chin and pubis. 

When the reduction is effected place a compress on the seat of 
injury, and confine it with a body bandage, or a broad strip of adhesive 
plaster. 

Dislocation of the Bibs and Costal Cartilages. — The ribs 
may be dislocated upon the vertebras, upon the sternum, and upon 
each other. Saurel also speaks of chondro-costal dislocation : but as 
there are no true joints between the ribs and their cartilages a sepa- 
ration at this point should rather be regarded as a fracture. 

From the nature of the connections of the ribs with the vertebras 
by strong ligamentous bands, some surgeons have doubted the possi- 
bility of a dislocation, yet unquestionable instances of the kind are 
upon record, and particularly of the lower ribs. It is, perhaps, true, 
however, that in most cases there will be found associated with a dis- 
location fracture of the transverse process of the vertebra, or of the 
necks of the adjoining ribs. 

The injury will in all cases be found to result from heavy blows 
upon the back ; the displacement, which occurs in most cases is in- 
wards. 

Symptoms. — It will be exceedingly difficult to make out a clear diag- 
nosis in these cases from their similarity to fracture of the necks of 



DISLOCATIONS OF THE UPPEE EXTREMITIES. 517 

the ribs. Chelius says "that dislocation of the rib may be distinguished 
by its greater mobility, when the finger is run along it, and which is 
still more perceptible the nearer it approaches the hinder end ; by a 
particular rustling (which is not to be confused with that from frac- 
tured rib, or from emphysema), which is perceived on the movements 
of the body and ribs by the practitioner, or by the patient himself; 
by a yielding of the parts covering the hinder end of the rib ; by a 
depression where the head of the rib should be found, and by motion 
of the hind end on pressure of the front end. It is accompanied with 
cough, difficult respiration, severe pain, and other symptoms, as in 
fractured ribs." 

The reduction may be attempted by placing the patient upon his 
back upon a firm mattress, and making firm pressure upon the ante- 
rior extremity of the ribs so as to force its head backwards into its 
natural position. Compresses may then be laid over the front and 
back of the chest, and confined by a thoracic bandage. 

The costal cartilages may be dislocated upon one another, particu- 
larly the seventh upon the eighth, the eighth upon the ninth, and the 
ninth upon the tenth, between which there are joint-surfaces incrusted 
with cartilage, lined with synovial membrane, and connected by liga- 
ments. 

The injury results from the violent bending backwards of the body, 
and presents the following symptoms : acute pain over the cartilage 
from any exertion, prominence of the overlapping piece, with a cor- 
responding depression by its side over the piece beneath ; some dis- 
turbance of the respiration, and a dull creaking sound may be heard 
when the chest walls move in forced breathing. 

The reduction is easily effected by directing the patient to bend his 
body backward, and making pressure upon the displaced cartilage, 
over which a compress is now to be placed, and confined by a body 
bandage. 

A chondro- sternal dislocation may take place by the cartilage being 
depressed beneath the sternum. It generally happens in children of 
weakly constitution, and will be recognized by a depression at the 
seat of injury; the reduction may be attempted by directing the 
patient to take deep inspirations. The after-treatment requires the 
thoracic walls to be kept at rest by a broad bandage. 

SECTION II. 

dislocations of the upper rxtremities. 
Dislocation of the Clavicle. 
I. Inner Extremity. 

1. Forwards. 

2. Upwards. 

3. Backwards. 
II. Outer Extremity. 

1. Upwards. 

2. Downwards. 

3. Downwards under coracoid process. 
III. Dislocation of Both Extremities. 



518 



PAKTICULAK DISLOCATIONS, 



Fig. 458. 



I. Dislocation of the Innee Extkemity of the Clavicle. - 
The inner extremity of the clavicle is held in connection with the 
sternum by a capsular ligament forming a joint, divided into two com- 
partments by an inter-articular cartilage, in the same manner as seen 
in the temporo-maxillary articulation. This connection is still farther 
strengthened by a ligament passing between the two clavicles, and also 
one between the clavicle and first rib, which all together form an arti- 
culation of considerable strength ; so that it is uncommon to find a 
dislocation at this point. When it does happen, the displacement may 
occur in either one of three directions ; forwards, upwards, or back- 
wards; the former being the most frequent. 

1. Dislocation forwards. — It may be complete or incomplete; in the 
former case, the capsular ligament will be torn through ; the inter- 
articular cartilage will sometimes be carried forwards with the end of 
the clavicle, and sometimes remain connected with the sternum ; the 
costo-clavicular ligament will be much stretched, frayed, or even torn ; 
in the latter the capsular ligament is only forcibly stretched. 

Causes. — The most common cause of this variety of luxation is 
some sort of violence applied to the back part of the shoulder, which 

drives the clavicle obliquely forwards 
and inwards, as when a person falls 
upon the shoulder from a height. 
(Fig. 458). Other causes have also 
produced it; pressure of the shoul- 
ders together by being caught between 
a carriage wheel and a wall; falls 
upon the elbow when the arm is 
thrown forward; muscular exercise, 
in swinging the dumb-bells, or en- 
deavoring to support a weight upon 
the head or shoulders. Boyer has 
seen a case in a young girl who sud- 
denly threw her shoulders backwards 
to assume a more graceful attitude. 

Symptoms. — At the time of the in- 
jury some pain will be felt at the top 
of the sternum, upon the front of which a hard tumor formed by the 
extremity of the clavicle will be seen, which changes its position 
when the shoulder is moved ; the sterno-clavicular articulation pre- 
sents a depression instead of its natural prominent outline. The 
shoulder is raised with difficulty, thrown backwards, and brought 
nearer the median line ; in tracing the line of the clavicle with the 
fingers it will be found to be more oblique, running forwards and 
downwards and inwards from the shoulder ; the clavicular portion of 
the tendon of the sterno-cleido-mastoid muscle is prominent and 
tense ; the head of the patient inclines to the injured side. 

Prognosis. — This luxation is not attended with danger, and though 
the surgeon may not be able to keep it reduced, little injury is inflicted 
thereby upon the functions of the limb. 




Dislocation of the sternal end of the 
clavicle forwards. 



DISLOCATION OF INNER EXTREMITY OF CLAVICLE. 519 

Treatment. — The indications of treatment are, first, to reduce the 
luxation, and second, to maintain it thus until the lacerated ligaments 
shall have regained sufficient strength to prevent any further dis- 
placement. 

For fulfilling the first indication, the patient is seated upon a chair, 
the surgeon standing behind him places his right knee between the 
scapulae, and seizing the two shoulders in his hands he draws them 
back, which, with a little pressure upon the displaced extremity of the 
bone, will effect the reduction : or he may accomplish the same object 
by making a lever of the arm of the injured side ; while the left hand 
supports the corresponding axilla, his right is used to grasp the elbow, 
and, carrying it backwards, he forces the clavicle into its natural 
position. 

To answer the second indication, various apparatus have been pro- 
posed, yet it is very difficult, in many instances, to succeed with any 
of them. It is fortunate, therefore, that so little inconvenience results 
from an unreduced luxation. 

A very simple plan is recommended by Nekton, who employed an 
ordinary hernial truss, the anterior pad of which is intended to make 
pressure over the sterno-clavicular articulation, while the posterior one 
takes a point cVappui in the axilla of the sound side. 

M. Melier made use of the apparatus of Brasdor for fractured cla- 
vicle, to the dorsal plate of which he fastened a steel spring curving 
over the injured shoulder, and furnished at its end with a concave pad 
for making pressure upon the inner extremity of the clavicle. 

Sir A. Cooper recommended an apparatus consisting of two padded 
rings for the shoulders buckling to two dorsal plates, which are to be 
drawn together by straps ; to prevent the plates being displaced up- 
wards, two straps also connect them with a belt encircling the body. 

"Whichever apparatus is employed, it will be necessary to keep it 
on the patient six or eight weeks, or even longer, in order to overcome 
the disposition to reluxation. 

2. Dislocation upwards. — This is a rare accident, and appears to have 
resulted in a majority of the recorded cases from a force acting upon 
the shoulder, pressing it downwards. 

When the luxation is complete, the ligaments are ruptured as in the 
preceding case. 

Symptoms. — The inner extremity of the clavicle is found forming a 
tumor upon the top of the sternum; or, perhaps, as seen in one case, 
is driven across the median line beneath the sterno-cleido-mastoid 
muscle of the opposite side; the space between the clavicle and first 
rib is increased, and at its bottom the semilunar notch upon the side 
of the sternum may be felt; the shoulder is depressed and inclined to 
the front, and the tendon of the sterno-cleido-mastoid is shoved promi- 
nently forward. Should the end of the clavicle press against the 
trachea, as it has been seen to do, difficult respiration will be added to 
the rest of the symptoms. 

Prognosis. — Considerable difficulty will be encountered in retaining 
the bone reduced ; and sometimes it is found impossible ; but in this 



520 PARTICULAR DISLOCATIONS. 

case even the patient will not suffer any material loss of power in the 
arm. 

Treatment. — The reduction is easily accomplished by drawing the 
shoulder upwards and slightly backwards, at the same time making 
pressure upon the clavicle from above downwards. As a retentive 
bandage, Yelpeau applied his apparatus for fractured clavicle, and 
kept it on fifty days without succeeding in keeping the luxation re- 
duced. Malgaigne believes this impossible without some remaining 
deformity. A gutta-percha splint may be moulded to the clavicle and 
ribs, and sustained in position by a roller bandage passing around the 
elbow and over the shoulder, and terminated by a few turns encircling 
the chest and arm, to retain the latter at rest. 

3. Dislocation backwards. — This kind of dislocation has been seen 
in thirteen or fourteen cases on record ; the inner extremity of the 
clavicle takes its position beneath the sterno-hyoid muscle, and is in- 
clined in some cases upwards, and in others downwards. 

Causes. — In a majority of the recorded cases the injury has resulted 
from crushing violence applied to the upper part of the chest ; in a 
few instances from the shoulders being violently pressed together 
between two objects ; or from falls upon the shoulder forcing it from 
behind forwards. 

Symptoms. — The symptoms are, difficulty in moving the shoulder 
and arm ; the shoulder approaches nearer the median line, and if the 
inner end of the clavicle inclines downwards, it will be elevated ; or it 
will be depressed if the inclination is in the opposite direction ; in the 
former case the slope of this bone being inwards and downwards, and 
in the latter inwards and upwards. A depression will exist over the 
semilunar notch into which the finger may be thrust ; and the patient's 
head inclines to the uninjured side. There is sometimes embarrass- 
ment of the respiration from pressure of the end of the clavicle upon 
the trachea. 

Prognosis. — In those cases in which reduction has not been accom- 
plished, the functions of the arm have not been impaired. 

Treatment. — The replacement of the end of the clavicle in the semi- 
lunar notch may be effected by drawing the shoulder upwards, out- 
wards, and slightly backwards, and the reduction should be maintained, 
if possible, by the posterior figure of 8 bandage, and a pad laid be- 
tween the scapulae. The same object may also be obtained by placing 
the patient upon his back with a small pillow between his shoulders. 

II. Dislocation of the Outer Extremity of the Clavicle. — 
Dislocations of the outer extremity of the clavicle are much more com- 
mon than those of the inner. Its articulation with the acromion pro- 
cess is less broad and less firmly bound together with strong ligaments 
than at the sternum, while the position of the joint at the tip of the 
shoulder is more exposed to the action of external forces. When de- 
tached from its natural connections with the scapula, the acromial end 
of the clavicle may be displaced upwards, downwards, or downwards 
beneath the coracoid process. 

1. Dislocation upwards. — This is the most common variety of the 



DISLOCATION OF OUTER EXTREMITY OF CLAVICLE. 521 



Fig. 459. 




Dislocation of the outer end of the 
clavicle, upwards and outwards. 



luxations of the acromial extremity of the clavicle ; and is either com- 
plete or incomplete. In the former case, 
the ligaments surrounding the joint will 
be completely ruptured, and the point of 
the clavicle will either rest upon the edge 
of the upper surface of the acromion pro- 
cess, or project across it to the extent of 
half or three-quarters of an inch. 

Causes. — The common cause producing 
this dislocation is a fall upon the point of 
the shoulder while the arm rests along 
side of the body. Malgaigne mentions a 
case produced by a fall upon the elbow, 
and Nelaton another from a heavy weight 
striking the clavicle from above. 

Symptoms. — The symptoms are, pain at 
the seat of the injury; the shoulder is 
slightly depressed and somewhat nearer 
the median line, the patient has great dif- 
ficulty in abducting the arm, which hangs 
by his side ; and in most cases he cannot 
place the hand upon his head ; the arm 

can, however, be moved freely backwards and forwards. The end of 
the clavicle will be found forming a hard tumor upon the top of the 
shoulder, terminating externally by a depression; in passing the fin- 
ger along the spine of the scapula, acromion, and clavicle, the latter 
will be felt thrown out of the continuous line which they naturally 
form. 

Diagnosis. — This injury has been mistaken for fracture of the clavi- 
cle and dislocation of the head of the humerus: but a careful compa- 
rison of the above symptoms and those of these two accidents will 
certainly prevent any blunder. 

Treatment. — The reduction is accomplished by carrying the shoul- 
der upwards and outwards, while at the same time pressure is made 
with the fingers upon the displaced bone. Here the difficulty begins ; 
for despite the application of the most ingenious contrivances the 
bone will generally slip from its place again and again. Should the 
dislocation remain unreduced, little harm comes of it, as the patient 
can use his arm with as much freedom as though nothing had hap- 
pened. 

The apparatus of Bartlett for fractured clavicle has sometimes suc- 
ceeded ; an additional strap is employed, which passes over the injured 
shoulder, and forces the clavicle downwards ; and thus counteracts the 
action of the clavicular insertion of the trapezius muscle. 

The apparatus of Desault answers the same indication, inasmuch as 
the third roller encircles the shoulder and elbow. 

M. Baraduc has suggested a somewhat similar bandage ; he encir- 
cles the arm with the turns of a roller to prevent the other parts of 
the dressing slipping, and places it by the side of the chest ; the first 



522 



PARTICULAR DISLOCATIONS. 



roller is applied circularly around the arm and chest, and compresses 
are placed upon the top of the shoulder, the luxation having been 
previously reduced ; then a second roller is made to pass over the 
shoulder, and under the elbow until seven or eight turns are laid on, 
and these are prevented from slipping by circular turns around the 
chest and arm. 

It has been attempted to make the necessary amount of pressure 
upon the clavicle with the ordinary tourniquet, the pad being placed 
upon the shoulder and the straps buckled beneath the corresponding 
elbow. 

Malgaigne has devised an apparatus consisting of a strongly woven 
band about four inches wide, and long enough to reach around the 
shoulder and elbow ; one of its ends is furnished with a buckle, and 
the other with a strap ; between these an elliptical piece is cut from 
the band. To apply it, place compresses over the acromial end of the 
clavicle, and upon the elbow ; slip the elbow into the elliptical hole of 
the band, which must now be buckled over the shoulder; to prevent 
the band slipping from the clavicle, a thoracic strap should be attached 
to it, passing around the uninjured side. 

M. Mayor recommends the apparatus seen in Fig. 460. It consists 
of a sling for the forearm, and two broad belts passing over the 

shoulders, and attached to it in 
. Fig. 460. front. 

2. Dislocation downwards. — 
It is a rare form of luxation, and 
but three cases have been re- 
corded. It results from blows 
upon the top of the shoulder, 
which displace the acromial end 
of the clavicle downwards be- 
neath the acromion process, and 
between it and the capsular lig- 
ament of the head of the hume- 
rus, and is accompanied with a 
rupture of the acromio-clavicu- 
lar, coraco-acromial, and coraco- 
clavicular ligaments. 

Symptoms. — The clavicle 
slopes outwards; a depression 
will be felt over the acromio- 
clavicular articulation, and, fur- 
ther outwards, an eminence, 
formed by the projection of the 
acromion process and the inferior angle of the scapula, projects back- 
wards. The arm can be moved freely forwards and backwards, but the 
motion of abduction will be much more restricted. 

Treatment. — The reduction in this case is accomplished by drawing 
the shoulders outwards, the knee of the surgeon having been previ- 
ously placed between the scapulas. 




Apparatus of Mayor for dislocation of the clavicle. 



DISLOCATION OF THE HUMERUS. 523 

There was no disposition to relaxation in the cases observed. 

M. Tournel employed in his case at first the bandage of Desault for 
fracture of the clavicle, and afterwards that of Flamand ; the cure was 
complete on the thirty-second day. 

3. Dislocation downwards under Coracoid Process. — Dislocation 
downwards under the coracoid process is also a rare form of luxation, 
there being six cases on record. It is caused by falls upon the shoul- 
der ; and has in the larger number of instances been observed among 
persons advanced in age. 

Symptoms. — The symptoms are depression and slight inclination 
forwards of the shoulder ; when the finger is passed along the border 
of the acromion process forwards, the clavicular prominence is found 
wanting, while the coracoid and acromion project boldly forwards ; 
the clavicle slopes outwards, and its distal extremity can be felt in the 
axilla. The inferior angle of the scapula is pushed outwards and 
backwards. 

Treatment. — To replace the luxated bone bring the elbow of the 
injured arm to the side of the chest, and while the surgeon supports 
it here in his left hand he puts his right hand in the axilla, and draws 
the upper extremity of the humerus outwards. After the reduction 
confine the arm to the side, and support the forearm in a sling. 

III. Dislocation of Both Extremities of the Clavicle. — M. 
Porral reports one case of this dislocation, and M. Goffres another. 
The latter happened in a woman from a fall between two rocks ; there 
were ecchymoses upon the anterior and external faces of the right 
shoulder; the internal extremity of the right clavicle was incompletely 
luxated forwards, and the outer extremity upwards. The reduction 
was easily accomplished, but could not be maintained ; and the patient 
was abandoned to her fate, the arm and forearm being supported in the 
scarf bandage of M. Mayor. At the end of forty days this was removed, 
and the patient resumed her occupation without the least restraint of 
motion of the arm, notwithstanding the persistence of the clavicular 
displacement. 

Dislocation of the Humerus. 

From the nature of the anatomical structure of the shoulder-joint, 
dislocation of the humerus is quite common. It may occur in one of 
three directions. 

1. Downwards. 

2. Forwards. 

3. Backwards. 

1. Dislocation downwards. — This is by far the most frequent variety, 
a fact readily explainable when the anatomical arrangement of the 
shoulder-joint is examined. The acromion and coracoid processes, 
with their ligaments, form a strong and resistant protection above, 
in front, and behind, while below there is nothing to prevent the 
head of the humerus slipping from the shallow glenoid cavity but 
the resistance offered by a thin capsular ligament, and by muscular 
contraction. 

Causes. — The causes are direct force applied to the shoulder, as 



524 



PARTICULAR DISLOCATIONS. 



"happens in falls ; blows upon the "upper part of the arm ; falls upon 
the elbow or hands when the arms are thrown forwards ; and muscu- 
lar action. 

Mechanism. — When a blow is struck upon the shoulder, the head 
of the humerus is, of course, driven directly from the glenoid cavity ; 
and, perhaps, in a majority of these instances, the arm at the time of 
the injury is more or less abducted. 

Indirect force upon the hand or elbow luxates the head of the bone 
by making a lever of the first kind of the humerus, the fulcrum being 
formed by its tuberosity coming against the margin of the glenoid 
cavity, and the point of resistance by the anterior and inferior part of 
the capsular ligament, which is usually considerably torn in front of 
the tendon of the long head of the biceps ; and even the latter is some- 
times ruptured, allowing the 
head of the bone to escape 
from the capsule and take a 
position beneath the glenoid 
cavity upon the subscapularis 
muscle near the triangular 
space of the inferior border of 
the scapula. 

The supra - spinatus, infra- 
spinatus, subscapularis, coraco- 
brachialis, and deltoid muscles 
are much stretched, and some 
of them, in certain cases, rup- 
tured. 

Symptoms. — The symptoms 
are : unusual prominence of the 
acromion process, and flatten- 
ing of the deltoid muscle ; the 
head of the humerus can be 
felt in the axilla ; the arm sepa- 
rated from the chest slopes out- 
wards and sometimes a little 
backwards, and cannot be brought in contact with it, though the arm 
may be moved to some extent forwards and backwards ; it is also 
slightly longer than the other arm ; the forearm is flexed a little 
upon the arm, and the patient cannot place the hand of the injured 
limb upon the opposite shoulder ; the head and neck incline to the 
injured side. Crepitus is sometimes heard when the arm is moved, 
probably depending upon erosion of the cartilage of the joint, and 
should put the surgeon on his guard not to mistake it for the crepitus 
caused by a fracture. 

Prognosis. — There will be no trouble in reducing a recent disloca- 
tion, and in many cases it has been effected after the lapse of weeks 
and even months, sometimes by manipulation, at others with certain 
mechanical contrivances. 

If the injury to the joint has not been very severe, the arm will be 




Dislocation of the shoulder downwards. 



DISLOCATION OF THE HUMERI'S. 525 

restored to its original usefulness, after reduction. In other instances, 
from extensive laceration of the capsule, rupture of the tendon of the 

Fie. 462. 




External appearance of dislocation of the shonlder downwards. 

biceps, or the supra- spinatus, or from some other cause, the arm 
remains stiff, and its functions impaired for months ; or it may even 
become paralyzed and atrophied from injury to the circumflex , and 
other nerves. 

In some cases the symmetry of the joint fails to be restored, the 
head of the humerus projecting considerably in front; aDd this may 
give rise to the supposition that the bone has been unreduced. 

Treatment. — Many methods have been suggested by surgeons, for 
the reduction of dislocation of the shoulder, from the time of Hippo- 
crates to the present moment. 

The chief obstacle to the reduction is the tension of the muscles, 
in which the supra-spinous and deltoid are principally in fault. The 
simple plan of relaxing these two muscles by carrying the elbow 
away from the chest will often suffice alone to return the bone. M. 
Lacour directs the patient to be seated upon a stool, an assistant stand- 
ing upon the uninjured side fixes the scapula with his hands; the 
surgeon now seizes the arm, bends the forearm at right angles with it. 
and makes extension, at the same time carrying the elbow from the 
body until the arm is at right angles with it ; then using the forearm as 
a lever, he rotates the humerus rapidly inwards and brings the elbow- 
to the chest, when the reduction will be completed. 

Some difficulty has been encountered in effecting the reduction by 
extension in fixing the scapula so that it may become a fixed point of 
counter-extension. To remedy this objection, Desault and Boyer 



526 



PAKTICULAE DISLOCA' 



advised the use of two bands to fix the shoulder, one crossing the 
acromion, and the other passing beneath the axilla ; their ends were 
pulled in the opposite direction to that of extension and fastened to 
a wall. 

For the same purpose Sir A. Cooper used an apparatus (Fig. 463) 
consisting of a broad band split at its centre to receive the shoulder, 
and having its two ends attached to a wall in the same manner as in 
the previous method ; the extending belt is fastened around the lower 

Fig. 463. 




Sir A. Cooper's method of securing the scapula with a counter-extending hand. 

part of the arm above the elbow ; the forearm is bent at right angles 
with the arm. 

Dr. Nathan Smith, of New Haven, endeavored to fix the scapula 
by making the counter-extension from the opposite wrist, and his son, 
Prof. N. K. Smith, of Baltimore, combines the methods of his father and 
Sir A. Cooper ; that is, he uses the counter-extending band seen in 
Fig. 464, and secures the wrist of the sound arm to it. 

A plan was pursued by Sir A. Cooper of making the extension in the 
line of the body, while the heel was pressed into the axilla. (Fig. 465.) 
He placed "the patient in the recumbent posture upon a table or sofa, 
near to the edge of which he is to be brought. The surgeon then 
binds a wetted roller round the arm immediately above the elbow, 
upon which he ties a handkerchief; then he separates the patient's 
elbow from his side, and, with one foot resting upon the floor, he 
places the heel of his other foot in the axilla, receiving the head of 
the os humeri upon it, while he is himself in the sitting posture by 
the patient's side. He then draws the arms by means of the hand- 
kerchief, steadily, for three or four minutes, when, under common 
circumstances, the head of the bone is easily replaced; but if more 
force be required, the handkerchief may be changed for a long towel, 
by which several persons may pull, the surgeon's heel still remaining 



DISLOCATION OF THE HUMERUS. 
Fig. 464. 



527 




Smith's method. 



in the axilla. He generally bent the forearm nearly at right angles 
with the os humeri, because it relaxes the biceps, and consequently 
diminishes its resistance." 

Fig. 465. 




Sir A. Cooper's mode of making counter-extension -with the heel. 

This distinguished surgeon employed another method (Fig. 466), 
which, though not near so powerful as the preceding, will answer very 



528 



PARTICULAR DISLOCATIONS. 



Fi s- 466 - well in those cases where the ligaments 

and muscles are much relaxed — as in 
delicate females. The patient is seated 
in a chair, the surgeon, standing be- 
hind him, and upon the injured side, 
places his foot upon the seat of the 
chair, with his knee forced well up 
into the axilla, and then steadying 
the shoulder with one hand, he grasps 
the arm with the other, and presses 
it forcibly downwards and inwards. 

Mr. Skey believed that it was best 
to allow the scapula to have free 
play, so that the glenoid cavity may 
be drawn downwards, which he be- 
lieves will contribute to the reduc- 
tion. In the use of the pulleys he 
therefore discards the use of the band 
for fixing the scapula, and adopts a 
" well-padded iron knob (Fig. 467), 
which may represent the heel, from 
which there extend laterally two 
strong, straight branches of the same metal, each ending in a bulb or 
ring of about four inches in length, the office of which is designed to keep 

Fig. 467. 




Sir A. Cooper's mode of reduction with the 
knee in the axilla. 




Skey's iron knob for the axilla. 



the margins of the axilla as free from pressure as possible. The person 
of the patient should be placed on the back, or inclined over on to 



Fie. 468. 




Skey's method of operating with the iron knob and pulleys. 

the opposite side, and the cords passed up on each side of the shoulder, 
one in front and the other behind the joint (Fig. 468). The arm should 
be drawn downwards, as nearly as possible parallel to, and in contact 



DISLOCATION OF THE HUMERUS. 529 

with, the body. Extension should be made from the wrist, and, espe- 
cially in old cases, continued gradually. With the above plan he has 
succeeded in reducing a great many dislocations, whether occurring in 
very muscular men, or after some days or weeks, or even months' 
duration." 

In the methods which we have now described, extension is made 
downwards in the line of the body, but the reduction may be accom- 
plished by making extension upwards in the line of the body. This 
plan seems to have been practised by Brunus in the thirteenth cen- 
tury; by White, towards 1762; by Mothe, of Lyons, in 1776. While 
the" arm is being extended, counter-extension is made by the hand, 
foot, or knee placed on the top of the shoulder. White, of Manches- 

Fig. 469. 




Mothe's method of reduction, modified. 

ter, attached pulleys to the ceiling, and hoisted the patient from the 
ground by a fillet fastened to his wrist. 

Malgaigne directs a handkerchief to be bound to the patient's 
wrist, and its two extremities tied in a loop, which is thrown over the 
upper corner of a door, so that when the person raises his feet the 
weight of the body will be supported by the handkerchief. 

Jarvis's adjuster is a powerful instrument, and, manipulated with 
care, will be found exceedingly valuable in reducing old dislocations. 

In all cases where any difficulty is encountered, it will be advisable 
to put the patient thoroughly under the influence of chloroform, both 
for the purpose of releasing him from pain, as well as to obtain com- 
plete muscular relaxation. 

In making extension either with the hands or with pulleys, the 
direction should be nearly downwards — or certainly not higher than 
an angle of forty-five degrees, with a view to obviate the actions of 
the pectoralis major and latissimus dorsi. All jerking and traction 
in distorted lines can accomplish nothing but injury to the patient. 
Keduction of many ancient dislocations has been effected by Yelpeau, 
Malgaigne, Gibson, and others ; in these cases the redoubtable acci- 
dents to be feared are rupture of the axillary nerves and bloodvessels, 
inflammation of the tissues about the joint, and swelling and emphy- 
sema of the shoulder and axilla. 
34 



530 



PARTICULAR DISLOCATIONS 



2. Dislocation forwards. — This kind of dislocation presents two 
species, according to the position assumed "by the head of the humerus. 
In the first (subcoracoid), seen in Fig. 470, the head takes its position 
beneath the coracoid process, behind the tendon of the coraco-brachi- 
alis and short head of the biceps, and lies upon the subscapular mus- 



470. 




Fig. 471. 




Subcoracoid dislocation. 



Subclavicular dislocation. 



cle. In the second variety (subclavicular) (Fig. 471) the head rests 
beneath the clavicle, inside of the coracoid process, and behind the 
pectoralis major and minor muscles, upon that portion of the serratus 
magnus which covers the second and third ribs. 

The capsular ligament will usually be much lacerated ; and the del- 
toid, supra-spinatus, infra-spinatus, and subscapularis muscles much 
stretched, and the latter are sometimes ruptured. 

Causes. — The cases are blows upon the posterior surface of the 
shoulder driving the head of the humerus forwards; falls upon the 
hands or elbow, particularly when the arms are inclined backwards ; 
the continued action of a force upon the elbow after the head of the 
bone has been displaced in the axilla may shove the head either 
beneath the coracoid or clavicle ; and lastly, muscular action. 

Symptoms. — The acromion will project markedly, with a depres- 
sion below, very evident a little posteriorly ; the head of the humerus 
can be felt in the subclavicular fossa forming a distinct hard tumor, 
though in subcoracoid dislocation the tumor will be farther from the 
median line in front of the shoulder, as seen in Fig. 472 ; the elbow is 
close to the side of the body, and inclines backwards; the arm is 
slightly shortened, and cannot be moved without causing lively pain ; 
neither the surgeon, nor the patient himself can place the hand of the 
injured arm upon the opposite shoulder; and lastly, the head and 
neck incline to the injured side. 

Prognosis. — The prognosis in uncomplicated cases is as favorable as 
in the previous variety ; but the reduction becomes much more diffi- 
cult after the lapse of a few days. 

Treatment. — The same principles of treatment hitherto described for 



DISLOCATION OF THE HUMERUS. 



531 



luxations downwards are applicable also in this variety. Both Vel- 
peau and Malgaigne direct, as the most rational practice, that the arm 
be extended at right angles to the chest. 

Fig. 472. 




Subcoracoid dislocation. 

3. Dislocation hackioards. — It also presents two varieties. In one 
the head of the humerus takes a position beneath the acromion (suba- 
cromial), and in the other beneath the spine of the scapula (sub- 
spinous). It is a rare form of injury, and but few cases have been 
reported. 

Causes. — It has happened chiefly from falls upon the elbow directed 
forwards, or upon the shoulder. The 
head of the humerus raptures the cap- Fig. 473. 

sular ligament at its posterior part, es- 
caping between the tendon of the triceps 
and the inferior angle of the acromion, 
and either rests beneath this process, or 
passes further along under the spine, as 
seen in Fig. 473 ; the tendon of the sub- 
scapularis muscle being often ruptured. 
The head of the bone is covered in by 
the infra-spinatus, teres minor, and del- 
toid, though it sometimes happens that 
the head escapes between the two for- 
mer, and is found beneath the deltoid 
only. 

Syrnjrtoms. — Subacromial depression 
will be well marked, and the coracoid subspinous dislocation. 




532 PARTICULAR DISLOCATIONS 






process will be seen prominent in front ; the head of the humerus can 
be felt beneath the spine of the scapula ; the elbow is close to the 
side, and projects forwards across the chest ; the arm is slightly longer 
than the opposite one, and its movements are restrained, but not so 
much so as in the other varieties of dislocation. 

Treatment. — In some cases the simple abduction of the arm has 
effected the reduction, while in others it will be necessary to rotate 
the arm inwards after abducting it. 

M. Lacaussade succeeded perfectly by carrying the elbow backwards, 
while he pressed the head of the humerus strongly forwards. 

Dislocations of the humerus may be complicated with fracture 
through its anatomical or surgical necks, of its tuberosities or of the 
coracoid or acromial processes, or lastly, of the glenoid fossa. 

It may also be compound or complicated with injury to the axillary 
nerves and bloodvessels. In treating such complications, the general 
rule to follow is, where a fracture is present endeavor, if possible, to 
reduce the dislocation, and then treat the case as one of fracture. This 
cannot always be done, however; and the surgeon will be compelled 
to wait until the broken bones are united, and afterwards try. to effect 
the reduction. 

Aneurism and laceration of the axillary vessels are to be opposed, 
after reduction, by the means directed in general works on surgery. 

Dislocation of the Eadius and Ulna. 

I. Dislocation of the Eadius and Ulna. 

1. Backwards. 

2. Forwards. 

3. Outwards. 

4. Inwards. 

5. Eadius forward and ulna backwards. 
II. Dislocation of the Eadius. 

1. Backwards. 

2. Forwards. 

3. Outwards. 

III. Dislocation of the Ulna. 

a. Upper extremity. 

Backwards. 

b. Lower extremity. 

1. Forwards. 

2. Backwards. 

I. Dislocation of the Eadius and Ulna. — 1. Dislocation of the 
Radius and Ulna backwards. — It may be complete or incomplete ; in 
the former case the coronoid process of the ulna occupies the olecranon 
fossa, while the head of the radius rests above the epicondyle. The 
condyles of the humerus force the brachialis anticus and the biceps 
strongly forwards, stretching and sometimes lacerating them; the 
brachial artery and median nerve are also pressed upon ; the anterior 
and lateral ligaments are also usually torn through (Fig. 474). 

Causes. — The causes are direct blows upon the upper and front part 



DISLOCATION OF THE RADIUS AND ULNA 



533 



of the forearm, or upon the lower and back part of the arm ; and most 
commonly falls upon the hands or elbow while the arms are thrown 



Fig. 474. 



Fig. 475. 





Dislocations of the radius and ulna backwards. 

forwards ; violent rotation and forced flexion of the forearm may also 
cause it. 

Symptoms. — The forearm is somewhat flexed and shortened, and the 
functions of the elbow-joint nearly abolished ; the hand is supinated 
and can be pronated but slightly ; the olecranon process projects pos- 
teriorly and its tip will be some distance above a transverse line con- 
necting the epicondyles; a tumor is formed in the bend of the elbow 
by the projecting condyles of the humerus (Fig. 475). 

Prognosis. — In simple cases the reduction may be effected promptly, 
and it is rare for any bad consequences to follow if much injury has 
not been inflicted upon the joint ; however, even after the bones are 
replaced, the motion of the joint will be much impaired, even if an- 
chylosis does not follow. 

Treatment. — There are several simple methods of reducing a dislo- 
cated elbow. The first is that practised by Nelaton : the forearm is to 
be bent at right angles with the arm, a short splint is bound to the 
posterior surface of the arm with its lower edge pressing against the 
olecranon ; then the surgeon simply extends the forearm, when the 
splint will force the olecranon downwards towards its fossa. A second 
plan (Fig. 476), that recommended by Sir A. Cooper, consists in mak- 
ing the patient sit upon a chair, " and the surgeon, placing his knee on 
the inner side of the elbow-joint, in the bend of the arm, takes hold of 
the patient's wrist, and bends the arm. At the same time he presses 
on the radius and ulna with his knee, so as to separate them from the 
os humeri, and thus the coronoid process is thrown from the posterior 
fossa of the humerus ; and whilst this pressure is supported by the 



534 



,OCATIONS. 




Reduction with the knee in the bend of the 
elbow. 



knee, the arm is to be forcibly but 
slowly bent, and the reduction is soon 
effected." 

The same object may be obtained by 
bending the arm around a moderate- 
sized stancheon, instead of the knee. 
Still a third way is sometimes had 
recourse to ; the surgeon directs an 
assistant to make extension from the 
wrist, or, as Pirrie advises, from the 
middle of the forearm, drawing the 
arm straight, while he with his two 
thumbs presses the olecranon down- 
wards, until the coronoid process is 
on a level with the trochlea ; then he 
presses it directly forwards, the assist- 
ant, at the same time, being requested 
to flex the forearm. 

When the reduction has been suc- 
cessful, the forearm can be extended 
and flexed without causing much pain 
or resistance ; and there is little dis- 
position of the bones to become re- 
luxated in consequence of the pecu- 
liar anatomical arrangement of the 
joint surfaces. It will be necessary to simply support the forearm in 
a sling, and quell inflammatory action by the application of cold 
water-dressings or other antiphlogistic remedies, to the joint; at the 
end of eight or ten days commence passive motion to prevent anchy- 
losis. 

2. Dislocation forwards. — Some eminent surgeons, among whom we 
find Sir A. Cooper, deny the possibility of this luxation without a 
fracture of the olecranon process; but there are now some six well- 
authenticated cases upon record ; so that it must be accepted as a pos- 
sible accident. It is either incomplete or complete ; in the former case 
the apex of the olecranon rests upon the trochlea, and in the latter, in 
front of this articular surface ; usually the olecranon deviates to the 
right or left. 

Causes. — The olecranon is thrown in front of the lower end of the 
humerus, by violent twisting of the forearm while the arm is either 
forcibly extended or flexed. 

Symptoms. — In Yelpeau's case the forearm was bent at right angles 
with the arm, and the elbow immovable ; the rounded lower extremity 
of the humerus projected backwards in the place of the sharp-outlined 
olecranon ; the forearm was strongly supinated and slightly shortened, 
the olecranon occupied a position upwards and outwards, while the 
head of the radius lay in the coronoid fossa. 

Treatment. — When the tip of the olecranon rests upon the trochlea, 
reduction may be accomplished by either flexing or extending the 
forearm. In complete dislocation, forced flexion is necessary, and, 



DISLOCATION OF THE RADIUS AND ULNA. 



535 



perhaps, extension from the wrist and counter-extension from the 
lower third of the arm. 

3. Dislocation of the Radius and Ulna outwards (Fig. 477). — This is 
an unusual form of injury, and is either incomplete or complete : in the 
former instance the greater sigmoid notch embraces the depression 
separating the trochlea of the humerus from the external condyle, or 
it moves still further outwards and backwards ; so that the coronoid 
process rests upon the posterior surface of the external condyle, while 
the posterior plane of the olecranon turns outwards, throwing the 
head of the radius forwards (dislocation backwards 

and outwards). In complete luxation both bones Fig. 477. 

abandon completely the posterior and inferior sur- 
faces of the humerus, mo vino- outwards ; the radius 

O 7 

in most cases beino- thrown forwards or backwards, 
generally the former, in consequence of the annu- 
lar ligament being ruptured. 

In these cases the lateral ligaments are severely 
stretched, and, in complete luxation, ruptured ; the 
fibres of the brachialis anticus and anconeus mus- 
cles suffer in a similar manner. 

Causes. — The injury results from blows near the 
elbow upon the inner side of the forearm, or outer 
side of the arm ; or from two forces operating 
upon these points in opposite directions ; from falls 
upon the elbow or hands in the efforts of a person 
to prevent his body striking the ground; and 
from violently twisting the forearm. 

Symptoms. — The elbow is increased in breadth, 
and there will be a notable prominence of the head 
of the radius upon its outer border, and a corres- 
ponding depression upon its inner border beueath 
the internal condyle; when the coronoid process 
is behind the condyle, the olecranon projects pos- 
teriorly and is above a horizontal line passing 
between the condyles ; the motions of the elbow-joint are nearly 
abolished ; the forearm is flexed upon the arm at an angle of about 
135 degrees and strongly pronated, and appears to be twisted upon 
its axis ; so that its inner surface looks posteriorly and the posterior 
surface outwards. 

Prognosis. — The prognosis is of the same character as when the 
bones are dislocated posteriorly. 

Treatment. — When the ulna takes a position behind the external 
condyle, the same manoeuvres will be required as those described for 
posterior luxation. In complete dislocation, extension from the hand 
and counter-extension from the lower part of the humerus will be 
required, while the surgeon presses the bones with his fingers in 
opposite directions to their displacement. When the head of the 
radius is thrown forward upon the ulna, the forearm must be supinated 
before the extension is made. 

4. D islocation of the Radius and Ulna inwards (Fig .47 '8). — This is a still 




Incomplete dislocation, 
outwards. 



536 



PARTICULAR DISLOCATIONS 



Fig. 478. 



rarer form of dislocation than the preceding, a fact depending, doubtless, 
upon the shape of the joint-surfaces — the trochlea sloping from within 
outwards offers more resistance to a force tending to drive the ulna 
towards the inner condyle. It may also be incomplete or complete ; 
in the former variety, the sigmoid cavity embraces 
the inner condyle, and the head of the radius is 
drawn inwards beneath the trochlea, or the coronoid 
process moves back behind the inner condyle, and 
the head of the radius reposes in the olecranon fossa, 
as happens in some cases. In complete luxation, 
the bones are entirely separated from the lower and 
posterior surfaces of the lower end of the humerus. 
The lateral ligaments are stretched or torn, and 
the fibres of the anconeus and tibialis anticus suffer 
more or less in the same manner. From the position 
of the olecranon over the course of the ulnar nerve 
this may be pressed upon or even crushed. 

Symptoms. — The arm is bent, and the forearm 
generally strongly pronated ; the external condyle 
is prominent ; and from the absence of the head of 
the radius, a depression will be found below it ; the 
head of the radius commonly remains beneath the 
trochlea, though it will sometimes form a tumor by 
projecting anteriorly in the bend of the elbow. 
The olecranon forms a prominence upon the inner 
side of the arm in the position of the epicondyle ; 
if the coronoid process is behind the inner condyle, 
the forearm will be shortened. The prognosis and 
treatment are the same as for dislocation outwards. 
5. Dislocation of the Radius forwards, and the Ulna backwards. — 
Three cases of this injury are recorded, and from them it may be 
gathered that the symptoms characterizing this luxation are a com- 
bination of those presented by dislocation of the radius and ulna 
separately, and that the treatment must be conducted upon the prin- 
ciples applicable to them. 

II. Dislocation of the Eadius. 1. Dislocation of the Radius 
backwards. — This is the most common form of the dislocations of the 
radius, and is not unfrequently associated with fracture of the con- 
dyles or of the upper end of the radius. 

The head of the radius, rupturing the annular, oblique, and capsu- 
lar ligaments, escapes from the lesser sigmoid notch, and takes up a 
position behind and to the external side of the outer condyle. 

Causes. — The causes are falls upon the palms of the hands, while 
the forearm is strongly pronated; raising persons from the ground by 
the hand, particularly children; and finally, direct blows upon the 
front and outer margin of the forearm. 

Symptoms. — The forearm is semiflexed and pronated; supination is 
impossible; flexion and extension limited and painful; the natural 
convex outline of the outer margin of the forearm is flattened; the 




Incomplete dislocation 
inwards. 



DISLOCATION OF THE RADIUS. 



537 



Fig. 479. 



biceps tendon is tense; and the head of the humerus can be felt 
behind the outer condyle, beneath which there is a marked depression. 

Treatment. — Make extension from the wrist, and counter-extension 
from the arm ; then forcibly supinate the forearm; the reduction may 
be facilitated by making pressure upon the head of the radius from 
behind forwards with the thumbs. When the bone is restored to its 
natural position, the arm may be kept in a straight posture, the 
tendon of the biceps will thus be made to aid in maintaining the 
reduction; passive motion must be instituted in eight or ten days. 

If accompanied with fracture of the inner condyle, Markoe recom- 
mends the arm to be supported by a splint, in a position about ten 
degrees less than a right angle. 

2. Dislocation of the Radius forwards (Fig. 479). — In this luxation the 
head of the radius is thrown forwards upon the humerus; the an- 
terior lateral and annular ligaments 
are more or less torn, though in 
some cases the latter may be only 
stretched. The dislocation is either 
incomplete or complete. Goyrand 
{Annates de la Chirurgie Francaise, 
1842, vol. v. p. 129) describes the 
former as a slight displacement of 
the head of the radius forwards, 
occurring in children from being 
lifted from the ground by their 
hands, or being held by the hand 
when they stumble and fall. 

Causes. — The causes are, falls 
upon the palms of the hands, vio- 
lent pronation of the forearm, a 
direct blow upon the upper and 
posterior part of the radius. 

Symjjtoms. — When a child suf- 
fers from an incomplete luxation, 
it cries out immediately with pain 
of the arm, which is slightly bent 
and the forearm pronated ; supina- 
tion being impossible or extremely 
difficult; and the elbow is not 

swollen. In complete dislocation the head of the radius will be felt 
in the fold of the arm ; there will be a depression beneath the exter- 
nal condyle ; the curved outline of the radial border of the forearm 
will be flattened. Delpech states that the forearm will be generally 
found supinated; while Malgaigne and other surgeons regard pronation 
as the characteristic position. Certain cases have also been observed 
where the forearm was midway between pronation and supination; 
the arm is slightly bent, the tendon of the biceps relaxed, and flexion 
of the forearm beyond a right angle impossible. 

Treatment. — Goyrand advises that extension should be made from the 
wrist with the surgeon's right, hand, and counter-extension with the left, 




Dislocation of the radius forwards. 



538 



PARTICULAR DISLOCATIONS 



Fi S- 48 °- -upon the lower part of the humerus, 

the thumb of this hand being placed 
upon the head of the radius. While 
extension is being made, supinate 
the forearm ; then suddenly flex it 
as much as possible, the thumb 
pressing strongly outwards upon the 
radius all the time. Assistants may 
make the extension and counter- 
extension while the surgeon presses 
the head of the radius backwards 
with his thumb. Sir A. Cooper di- 
rects the arm to be supinated, while 
Denuc^ recommends the prone pos- 
ture during extension. 

The dislocation is apt to.be repro- 
duced when the forearm is extended, 
and it will be advisable, therefore, 
to place the arm in an angular splint, 
with a compress over the head of the 
radius. 

3. Dislocation of the Radius out- 
wards. — This is sometimes a primary 
luxation, but more commonly conse- 
cutive to either the anterior or pos- 
terior dislocations. 

Symptoms. — The head of the ra- 
dius forms a prominence outside of 
the epicondyle, giving a greater width, as well as a greater convexity 
to the upper part of the forearm, which is in a position midway 
between supination and pronation; complete supination being impos- 
sible, though extension and flexion can be performed. 

Treatment. — The reduction may be effected by bending the arm at 
right angles, and making extension and counter-extension from the 
wrist and lower part of the arm ; at the same moment the surgeon 
will press with his thumb the head of the radius downwards and in- 
wards, to its normal position beneath the condyle of the humerus. 

The bone is liable to slip out of position again in the movements of 
the forearm ; and it will be necessary, in order to counteract this, to 
keep the arm in a flexed position, with a compress upon the outer side 
of the elbow by an angular splint, with bandages. 

III. Dislocations of the Ulna. a. Dislocation of the Upper .Ex- 
tremity of the Ulna. — Dislocation of the ulna backwards may occur, 
though it is rare, and usually accompanied with fracture of the outer 
condyle of the humerus, or fracture of the neck of the radius. 

Malgaigne states that the only peculiarity of this luxation is, that 
the head of the radius can be felt in its natural position, the other 
symptoms being the same as those of dislocation of both bones back- 
wards. The reduction is also accomplished in the same manner as 
directed for this luxation. 




External appearance of a dislocation of the 
radius forwards. 



DISLOCATION" OF CARPUS UPON RADIUS AND ULNA. 539 

b. Dislocation of the Lower Extremity of the Ulna. 1. Dislocation 
of the lower end of the Ulna forwards. — In this form of luxation the 
stylo-pisiform and capsular ligaments are torn, and the lower end of 
the ulna is thrown in front of the radius. 

Causes. — Forced supination of the forearm. 

Symptoms. — The arm is slightly bent; the forearm supinated; and 
the hand inclined to its radial border ; the fingers are semi-flexed ; 
there is a depression upon the inner side of the forearm above the 
wrist, caused by the ulna sloping across the lower part of the radius ; 
the styloid process can no longer be felt in its prominent position upon 
the inner border of the wrist, which is diminished in width, and 
rounded ; and lastly, the point of the ulna forms a tumor in front of 
the radius. 

Treatment. — The bone may be restored to its natural position in the 
following manner : The surgeon seizes the forearm in both his hands, 
with the thumbs placed between the bones, and the fingers steadying 
the radius ; and while an assistant pronates the forearm he shoves the 
ulna in position with his thumb. If there is any disposition of the 
ulna to become reluxated, two padded splints may be confined to the 
forearm with a roller bandage. 

2. Dislocation of the Lower End of the Ulna backwards. — This is 
exactly the reverse of the preceding luxation; the distal extremity of 
the ulna is thrown upon the posterior surface of the radius. 

Causes. — It is caused by violent pronation of the forearm. 

Treatment. — The arm will be found slightly bent, and the forearm 
pronated ; the hand and fingers are semi-flexed ; the point of the ulna 
forms a tumor on the back of the wrist, which is diminished in width 
by the overlapping of the two bones below. 

Treatment. — The same manipulation may be employed in this case 
as in dislocation forwards, with this difference, that as the surgeon 
presses the ulna inwards with his thumbs, the assistant must supinate 
the forearm. 

Dislocation of the Carpus upon the Eadius and Ulna. 

Dislocation of the Carpus — 

1. Backwards. 

2. Forwards. 

1. Dislocation of the Carpus backwards (Fig. 481). — The causes of this 
injury are direct violence inflicted upon the wrist, driving the carpus 
backwards, and falls upon the hands in a flexed position. The carpus is 
forced upon the posterior surface of the radius under the extensor ten- 
dons, which are stretched over its upper extremity ; the ligaments of 
the wrist-joint are more or less torn; and the arteries, nerves, and 
muscles in the neighborhood bruised. The dislocation is sometimes 
compound, and at others complicated, with a fracture of the lower 
end of the radius or ulna. 

Symptoms. — The forearm is shortened when measured from the 
olecranon to the tip of the middle finger, while the distance between 
the former point and the styloid process remains unchanged ; there is 
a large prominence formed by the carpus upon the back of the fore- 



540 



PARTICULAE DISLOCATIONS. 




Dislocation of the carpus backwards. 



Fi g- 481 - arm, and another in front, caused by 

the lower projecting ends of radius 
and ulna, below which there is a 
well-marked depression; the sty- 
loid processes are not in the same 
line as the carpal bones ; the wrist is 
much thicker than natural, and the 
fingers are semi-flexed. 

Treatment. — Compound disloca- 
tion of the wrist often requires amputation or resection ; but perfect 
rest, cooling lotions, and other antiphlogistic remedies will accom- 
plish much in some of these cases in securing a favorable issue with- 
out operation ; though anchylosis and excessive inflammation with 
profuse suppuration are at all times to be feared. 

The carpus may be restored to its articular relation by directing an 
assistant to make counter-extension from the forearm, while another 
grasps the metacarpus and effects extension ; the surgeon then en- 
deavors to push the carpus downwards with his thumbs. 

Malgaigne states that in the above plan the hold upon the meta- 
carpus is not sufficiently firm, at the same time it puts the skin on the 
stretch and opposes in some measure the reduction. His method is to 
make the extension by grasping the last four fingers, and with a lac 
fastened around the metacarpus above the roots of the fingers. 

2. Dislocation of the Carpus for - 



Fig. 482. 




Dislocation of the carpus forwards. 



wards (Fig. 482). — In this variety 
of dislocation the carpus is thrown 
forwards upon the anterior face of 
the radius. 

The causes, symptoms, and 
treatment are the reverse of those 
of dislocation backwards. 



Dislocation of the Carpal Bones upon each other. 

The carpal bones are so strongly bound together by ligaments, and 
protected by the tendons crossing them at the wrist, as well as possess- 
ing such a limited range of motion, that a simple dislocation is rather 
of an uncommon occurrence. 

The os magnum is thrown backwards by falls upon the back of the 
hand, violently flexing it. I saw a case of a young lady who fell from 
her horse upon the hand. A tumor was observed upon its back, which 
could be made to disappear by firm pressure upon it, but returned 
immediately when the hand was flexed ; a compress was placed over 
the os magnum, and two straight splints upon the forearm secured by 
a roller bandage ; after the treatment the wrist remained weak for 
several months, and there was a slight prominence at the seat of the 
injury. 

Should simple pressure not suffice to reduce the bone, extension 
should be made at the same time from the index and middle fingers. 

Sir A. Cooper states that both the os magnum and cuneiform may 



DISLOCATION OF THE METACARPUS. 5-il 

be displaced backwards from relaxation of the ligaments ; and in the 
case of a young lady in whom it occurred, she was compelled to wear 
two short splints to strengthen the wrist; for the same purpose another 
lady wore a broad steel-chain bracelet clasping the wrist tightly. 

Mr. Erichsen saw the case of a patient who fell from a height, 
injuring the spine and doubling the right hand under him. " On 
examining the wrist, a small hard tumor was felt projecting on its 
dorsal aspect, which usually disappeared on extending the hand and 
employing firm pressure, but started up again so soon as the wrist 
was forcibly flexed. It was evident that this bone belonged to the 
first row of the carpus, articulating with the radius ; and from its size, 
its position towards the radial side of the carpus, and its shape, w T hich 
could be distinctly made out through the integuments, there could be 
little doubt that it was the semilunar bone." 

Fergusson says : " I have known of one example in which the pisi- 
form bone was detached from its lower connections by the action of 
the flexor carpi-ulnaris. Little benefit can be expected from any 
attempt to keep this bone in its proper position, nor, indeed, is the 
displacement of much consequence." 

South states that the unciform is sometimes thrown backwards by 
the relaxation of the ligaments, and forms a projection on the back of 
the hand when it is flexed. The hand cannot be used without the 
wrist is supported, and he directs for this purpose the application of 
strips of adhesive plaster and a bandage. 

Dislocation of the Metacarpus. 

The limited amount of motion enjoyed by the metacarpal bones, 
their arrangement in a parallel row with their proximal extremities 
supporting each other like wedges, and bound together by strong 
ligamentous fasciculi passing between them and the carpus, render 
dislocation at the carpo- metacarpal articulation uncommon. 

The first metacarpal bone, from its exposed position upon the outer 
border of the hand, and the greater extent of motion possessed by it, 
is more frequently dislocated than any of the others. 

The luxation may occur backwards, or forwards and inwards. 

1. Dislocation of the First Metacarpal Bone backvjards. — This injury 
is caused by a force applied to its lower extremity, forcing it upwards 
and generally throwing the thumb into forced flexion ; it has also been 
produced by violence acting upon the anterior aspect of the bone. 

The ligaments surrounding the joint are more or less ruptured, and 
the proximal extremity of the bone is thrown upon the posterior 
surface of the trapezium. 

Symptoms. — There is a protuberance formed by the end of the bone 
upon the back of the hand ; the thumb is generally flexed and in- 
clined across the palm of the hand, and its motions abolished. 

Treatment. — The reduction is accomplished by making extension 
and counter-extension, and at the same time pressure downwards upon 
the displaced bone ; then apply a narrow splint, with a compress over 
the joint, upon the outer margin of the hand and wrist, if there is any 
tendencv to reluxation. 



542 



PARTICULAR DISLOCATIONS. 



2. Dislocation of the First Metacarpal Bone forwards and inwards. — 
Here the proximal end of the bone lies in front of the carpus between 
the trapezium and the root of the second metacarpal bone. 

Symptoms. — A tumor is formed in front towards the palm of the 
hand ; the thumb is thrown outwards, and its tip cannot be brought in 
contact with the point of the little finger, nor can it be adducted. 

The reduction may be attempted by making extension and gradu- 
ally carrying the thumb towards the palm of the hand; pressure out- 
wards upon the root of the bone may be made at the same time. 

3. Dislocation of the Outer Four Metacarpal Bones. — M. Bourguet 
has reported a case of luxation of the second metacarpal bone for- 
wards, and Blaudin and Koux, each, one of the third metacarpal bone 
backwards. * 

Dr. Hamilton relates two cases of an incomplete posterior luxation 
of the second and third metacarpal bones at the same time by the 
patient's striking a blow with the clenched fist. 

The symptoms are pain, swelling, and deformity over the carpo- 
metacarpal articulation. 

Treatment. — Extension from the finger of the displaced metacarpal 
bone, combined with pressure upon its proximal extremity. 

Should there be any disposition to a recurrence of the displacement, 
a straight splint with the necessary compresses should be applied to 
the hand. 

Dislocation of the Phalanges. 

A. Dislocation of the First Eow of Phalanges. — Dislocation 
of the first phalanx of the thumb is more frequent than any other, 
and may be complete or incomplete. It occurs backwards or forwards. 
1. Dislocation of the First Phalanx of the Thumb backwards. — This 
happens more frequently than in a forward direction. It is caused by 
any force doubling the thumb back upon the hand. When the luxa- 
tion is complete, the proximal end of the first phalanx takes a position 
behind the adjoining extremity of the metacarpal bone and at right 
angles with it, while the second phalanx is flexed and forms an angle 
with the first, so that the shape of the thumb will represent some- 
what the letter Z, as seen in Fig. 483 ; the distal 
Fig. 483. e nd f the first metacarpal bone forms a tumor in 

front of the thumb looking towards the palm. 
Sometimes, however, the first phalanx and the 
metacarpal bone lie in parallel positions, and this 
characteristic shape of the thumb will not be seen, 
and the tumor spoken of above as looking to- 
wards the palm will then present itself upon the 
posterior aspect of the thumb. 

Symptoms. — These changes of outline of the 
thumb, with abolition of its functions, will render 
the identification of the injury easy. 

Prognosis. — The reduction of this dislocation 
Dislocation of the first P ha- in receDfc cageg . somet i mes effected with ease ; 

lanx of the thumb back- . . . .. . . . ' 

wards . but there are cases in which great difficulty will 




DISLOCATION OF THE PHALANGES. 543 

be encountered from some peculiarity in the nature of the injury, 
which has not as yet been certainly and satisfactorily explained. 
Some surgeons attribute it to the rupture and interposition of the 
anterior ligament between the joint-surfaces; Hey to the lifting of 
the lateral ligaments over the end of the metacarpal bone which is 
constricted by them, and some again charge the difficulty to the mus- 
cles ; Vidal de Cassis says the distal extremity of the metacarpal bone 
is constricted between the two heads of the short flexor of the thumb ; 
there are others who think that the bones are at fault, and that the 
obstacle to reduction is the interlocking of the margins of their 
articular surfaces. 

Treatment. — There are various methods recommended for the re- 
duction of this dislocation ; some consisting in simple manipulation 
with the fingers, and others in the application of apparatus for 
extension. 

In the ordinary process by manipulation the surgeon presses the 
distal extremity of the first phalanx upwards so as to throw its articu- 
lating surface in the direction of the farther end of the metacarpal 
bone ; then supporting the phalanx in this position with the fingers, 
and pressing against the distal end of the metacarpal bone, the thumbs 
are forcibly pressed against the base of the displaced phalanx to throw 
it into its natural position. Dr. Batchelder, of New York, has im- 
proved this method in some particulars worthy of special notice. He 
directs the surgeon "to take the metacarpal portion of the dislocated 
thumb between the thumb and finger of one hand, and flex, or force 
it, as far as may be, into the palm of the hand, for the purpose of re- 
laxing the muscles connected with the proximal end of the phalanx, 
particularly the flexor brevis pollicis. He should then apply the end 
of the thumb of this hand against the displaced extremity of the dis- 
located phalanx for the purpose of forcing it downwards, and at the 
same time grasp the displaced thumb with his other hand, and move 
it forcibly backwards and forwards, as in strongly forced flexion and 
extension, the pressure against the upper extremity of the first 
phalanx being kept up. In this way the dislocated bone may be 
made to descend, so as to be almost or quite on a line with the 
articulating surface of the metacarpal bone, when the thumb may be 
forcibly flexed; and, if it be not reduced, is forcibly extended, and 
brought backwards to a right angle with the metacarpal bone ; when, 
if the downward pressure with the thumb, placed as before directed 
for that purpose, has been continued (which thumb, by maintaining 
its position, acts as a fulcrum, as well as by its pressure), the bone will 
slip into its place, and the reduction be effected." 

Should these manipulations not succeed, extension may be had 
recourse to (Fig. 484). For this purpose, Sir A. Cooper recommended 
that the thumb be adducted, to relax the muscles connected with the 
proximal extremity of the phalanx; a piece of soft leather was wrapped 
around this phalanx, and over this a lac is fastened by the clove-hitch; 
the surgeon, grasping the ends of the lac, will be enabled to make the 
required amount of traction, while an assistant seizes the hand of the 
patient with his fingers placed between the thumb and radial border 



544 



PARTICULAR DISLOCATIONS. 



of the palm, and makes the counter-extension ; or some wool may be 
put between the finger and thumb, and a counter-extending band be 
used. 

Another plan of this surgeon was to attach a weight to the lac 
running over a pulley. 

Fig. 484. 




Sir A. Cooper's method of making extension with a weight in dislocation of the thumb. 

A much more efficient way of making extension and of getting 
complete command over the thumb is with a very simple instrument 
contrived by Dr. Levis, of Philadelphia. It consists of "a thin strip 
of hard wood, about ten inches in length, and one inch, or rather more, 
in width. One end of the piece is perforated with six or eight holes. 

Fig. 485. 




Levis's instrument for reducing dislocation of the phalanges. 

The opposite end is partly cut away, forming a projecting pin, and 
leaving a shoulder on each side of it. Towards this end of the strip 
a sort of handle shape is given to it, so as to insure a secure grasp to 
the operator. Two pieces of strong tape or other material, about one 
yard in length, are prepared. One of these is passed through the 
holes at the end of the strip, leaving a loop on one side. The other 
tape is passed through another pair of holes, according as it may be 

Fig. 486. - 




Levis's instrument applied. 



a thumb or finger to which it is to be applied, or varied to suit the 
length of the finger, leaving a similar loop. If a dislocated thumb is 
to be acted on, the second tapes should be passed through the holes 
nearest the first. The ends of each separate tape are then tied to- 
gether." 



DISLOCATION OF THE PHALANGES. 545 

He directs the apparatus to be applied "by passing the finger 
through the loops. The loop nearest the first joint is then tightened 
by drawing on the tape, which is then brought along the strip to the 
opposite end, across one of the shoulders, and secured by winding it 
firmly around the projecting pin. The other tape is tightened in a 
like manner, crossing the other shoulder, and winding around the pin 
in an opposite direction; when, for security, the ends of the tapes are 
finally tied together." 

The same end, that of securing complete control over the motions 
of the thumb, was kept in view by Luer, of Paris, in constructing his 
forceps for the reduction of dislocated phalanges. The points of the 
forceps are bifurcated; between each pair of which a piece of strong 
cloth or canvas is stretched, to grasp the thumb firmly ; additional 
power may be gained by placing inside of the canvas two pieces of 
cork or caoutchouc. 

Charriere, of the same city, contrived a pair of forceps for the same 
purpose ; they were articulated at one extremity, in the same manner 
as an ordinary pair of dividers, and divided at the other into four 
prongs, to which four leather straps are attached in such a manner as 
to make two slip-knots, in which the thumb is to be placed, and held 
firmly by pressing upon the forceps. 

Dr. Hamilton suggested the employment of a toy called the " Indian 
puzzle," for making extension upon dislocated fingers. It "is an elon- 
gated cone of about sixteen or eighteen inches in length, made of ash 
splittings, and braided ; the open end of the cone being about three- 
Fig. 487. 




"Indian puzzle," employed for the reduction of dislocations of the phalanges. 

fourths of an inch in diameter, and the opposite end terminating in 
a braided cord. When applied to the finger, it is slipped on lightlv, 
forming a cap to the extremity, and to half the length of the finger ; 
but on traction being made from the opposite end it fastens itself to 
the limb with a most uncompromising grasp." 

With a view of making extension, and at the same time of flexing 
and extending the thumb Vidal de Cassis employed a common door 
key. He placed the ring over the dislocated thumb so that its palmar 
surface reposed upon the stem of the key, while that part of the cir- 
cumference of the ring opposite the stem rested against the dorsal face 
of the proximal extremity of the first phalanx. Seizing the key in the 
right hand, the thumb is forced into a position of dorsal flexion, at the 
same time sliding the articular surface of the phalanx in the direction 
of the articular surface of the metacarpal bone, when sudden flexion 
of the thumb will replace the bone in its natural position. 

Lastly, Malgaigne and Blandin have employed, in obstinate cases, a 
35 



546 



PAKTICULAR DISLOCATIONS. 



sharp-pointed metallic stem, which they forced through the skin be- 
tween the articular surfaces of the phalanx and metacarpal bone, and 
prized the former into its natural position. 

In some of these cases, which resist all the efforts of the surgeon at 
reduction, the subcutaneous division of the lateral ligaments is 
required. 

When the bone has been restored to its natural articular connec- 
tions, inflammatory action should be combated by appropriate anti- 
phlogistic measures ; and, to prevent the luxation recurring, a splint 
may be applied, and secured to the parts by the spica of the thumb. 

2. Dislocation of the First Phalanx of the Thumb forwards. — This 
form of dislocation is rare, and but few cases are recorded. It is caused 

Fig. 488. 




Dislocation of the first phalanx forwards. 

by blows upon the back of the phalanx, the proximal extremity, of 
which is driven in front of the metacarpal bone, forming a prominence 
in front. The phalanx and metacarpal bone are usually in parallel 
positions. 

Treatment. — The reduction is effected by seizing the thumb in the 
palm of the right hand and making extension, while the thumb of this 
hand makes counter-pressure upon the head of the metacarpal bone. 
If this plan fails, the phalanx should be flexed firmly towards the 
palm. In the cases reported no difficulties have been encountered in 
the reduction. 

3. Dislocation of the First Phalanges of the Fingers. — Dislocation of 
the first phalanges of the fingers is an uncommon injury. It may 
occur forwards or backwards, and be complete or incomplete. 

It is caused by blows upon the ends of the fingers, and is readily 

Fig. 489. 




Eeduction of dislocation of the phalanx backwards by extension. 

recognized by the deformity produced at the metacarpo-phalangeal 
articulation. 

Treatment. — Extension from the finger will effect the reduction, as 



DISLOCATION OF THE PELVIC BONES. 547 

seen in Fig. 489 ; or forced flexion in forward luxation, and the 
reverse in backward luxation will also be found efficient. 

B. Dislocation of the Second and Third Rows of the Pha- 
langes. — The phalanges of the second and third rows of the fingers 

Fig. 490. 




Dislocation of the second phalanx backwards. 

and thumb may be dislocated forwards or backwards. It is caused by 
blows upon the tips of the fingers, and is easily recognized by the 
deformity of the phalangeal joints. 

The treatment is the same as for dislocation of the first phalanges. 

SECTION III. 

dislocations of the lower extremities. 
Dislocation of the Pelvic Bones. 

From the strength of the articulations of the pelvis, dislocation of its 
component bones is of extremely rare occurrence ; and, when it does 
happen, the amount of violence necessarily inflicted will generally pro- 
duce fatal injury of the pelvic and abdominal organs. The luxation is 
always incomplete. 

Boyer relates a case of dislocation of the left ileum upwards by a 
fall from a height. The anterior superior spinous process was above 
the level of the corresponding point upon the opposite side ; the left 
pubis was some distance above the right ; the left leg was shorter than 
the right, but both of them measured the same length from the tro- 
chanter to the ankle ; flexion and extension of the thigh gave rise to 
pain in the pubic and sacro-iliac symphyses. 

A disturbance of the relation of the two bones has been observed, 
also, after difficult labor ; the patient cannot walk without great pain, 
from the motion of the bones at the symphyses, and requires the 
application of a broad bandage to the pelvis and hips to hold the 
bones in firm apposition. 

The sacrum may be driven slightly inwards by a violent blow 
upon the back of the pelvis, and the coccyx, before ossification, 
may be incompletely dislocated either forwards or backwards. In 
the former case, it results from blows or falls upon the part; and in 
the latter case, from the pressure of the head of the child in difficult 
labor. 

The reduction is easy. Introduce the point of the index finger into 
the rectum, and grasp the coccyx between the thumb and finger, 
pressing it in a direction opposite the displacement. There is no dis- 
position to reluxation. 



548 



PARTICULAR DISLOCATIONS. 



Dislocation of the Femur. 

The coxo-femoral joint is one of exceeding strength, the large 
globular head of the femur being held in a deep osseous cavity by 
strong ligaments, and protected by a mass of muscles surrounding the 
articulation, presenting a most perfect type of the ball-and-socket 
joint, which allows a wide range of motion. 

The dislocation usually occurs in four principal directions, back- 
wards and upwards upon the dorsum ilii ; backwards and upwards 
into the sciatic notch; forwards and downwards into the thyroid 
foramen; and forwards and upwards upon the pubic bone. From 
some peculiarity in the application of the force producing the injury, 
or from some other cause, it occasionally happens that the head of 
the femur passes in any direction intervening between these four, so 
that it has been found under the anterior-superior spinous process, in 
the lesser ischiatic foramen, upon the posterior part of the body of the 
ischium, below the lower margin of the acetabulum, and in the 
perineum. 

As to the relative frequency of the four principal varieties, Cooper 
and Malgaigne state it in the order in which they are mentioned 
above. It is most commonly met with in persons between the ages 
of twenty and forty-five, being rare in childhood and old age. Males 
suffer more often than females in the proportion of eight to one. 

1. Iliac Dislocation. — Iliac dislocation, or that where the head of 
the bone reposes upon the dorsum of the ilium, is caused by falls 
upon the knee or foot when the thigh is adducted, and somewhat in 



Fig. 491. 



Fig. 492. 





Iliac dislocation. Anatomical relation. 



Iliac dislocation. External appearances. 



advance of the body; or by blows upon the back of the pelvis when 
a person is stooping, with the knees widely separated. 



DISLOCATION OF THE FEMUR. 549 

The capsular ligament is ruptured, particularly at its posterior 
part, and the head of the femur is thrust upwards on the dorsum of 
the ilium among the fibres of the gluteal muscles, which are relaxed 
and folded upwards, while the adductor muscles are drawn tense. 
When the injury is severe, there will be more or less contusion and 
effusion of blood into the soft parts about the joint. 

Symptoms. — The patient cannot support the weight of the body 
upon the injured limb, which will be found, upon measurement from 
the anterior-superior spinous process of the ileum to the malleolus, 
from an inch and a half to three inches shorter than the other, the 
average being two inches, and cannot be drawn to its normal length, 
by moderate extension ; the thigh is rotated inwards, so that the knee 
touches the sound thigh just above the patella, and the great toe rests 
upon the instep of the opposite foot, as seen in Fig. 492 ; or upon the 
foot just below it. The trochanter is more prominent, and nearer the 
spine of the ilium, and in some persons the head of the femur can 
be felt in its abnormal position; flexion is easy, adduction less so, 
and abduction is impossible. 

Diagnosis. — Dislocation can be distinguished from fracture of the 
upper extremity of the femur by the following features : The short- 
ened limb cannot be restored to its normal length by moderate exten- 
sion ; the toes are turned in ; motion of the thigh at the hip much 
restricted ; and crepitus is absent. In fracture, these symptoms are 
exactly the reverse. 

Prognosis. — Dislocation of the femur is always a serious matter, 
though usually, in simple cases, where the reduction has been accom- 
plished, the limb, in two or three months, will become as strong as 
the sound one. Sometimes, again, it remains stiff and weak for 
months ; and in severer cases, occasionally inflammation of a chronic 
character will arise, producing ulceration of the cartilages and caries 
of the bone; or even acute inflammation may occur, followed by 
abscess. 

Treatment. — The dislocation may be reduced by manipulation, or 
by extension and counter-extension. In the first instance, chloroform 
having been administered, if deemed necessary, the patient is placed 
upon his back on a couch — or, better still, upon the floor, which will 
enable the surgeon to have greater command over the limb; he now 
seizes the knee of the injured limb in one hand, and the ankle in the 
other, and bends the leg upon the thigh ; then the knee is carried 
across the opposite thigh upwards in the direction of the correspond- 
ing side to the umbilicus, when it should be made to sweep across the 
abdomen to the injured side. From this position the thigh is gra- 
dually brought down or extended, the knee being pressed outwards, 
while the foot is conducted across the sound limb, until the thighs are 
side by side. 

In Fig. 493 the arrows and dotted lines indicate directions pursued 
by the knee and the head of the femur. 

It will be found that the reduction takes place when the thigh be- 
gins to descend from a right angle with the body ; and should it not 
occur at this time the movement may be recommenced. 



550 



FAETICULAE DISLOCATIONS. 



Should a resort to the pulleys be determined on, the patient should 
be placed on his back upon a narrow table, and thoroughly chloro- 



Fig. 493. 




Diagram showing the mechanism of redaction of the hip by the flexion method. 

formed. An extending band is fixed upon the lower part of the 
thigh, which may be the ordinary leather strap with buckles, applied 
over a wetted roller, or two pieces of some strong cloth, two feet long 
and about four inches wide, laid upon the sides of the limb, and 
secured above the knee by a wetted roller. The ends of the strips are 
then knotted together to form a loop upon each side of the thigh. 
The counter-extending band is prepared by rolling up a sheet into a 
cord, the centre of which is placed in the perineum, and its extremi- 
ties brought upwards over the hip of the injured side, to be fastened 
to a staple fixed in the wall. The pulleys are to be hooked at one 
end to a staple driven into the wall at an opposite point, and at the 
other to the extending band in such a manner that the extending and 
counter-extending forces shall act in opposite directions in the axis 
of the femur. The thigh of the injured limb should be bent some- 

Fig. 494. 




Method of reducing dislocated hip with pulleys. 

what upon the abdomen, so as to point across the opposite leg just 
above the knee, as seen in Fig. 494. 



DISLOCATION OF THE FEMUR. 



551 



An assistant should stand by the table, and with his hands steady 
the patient's hips; a second assistant takes hold of the leg to rotate 
the thigh gently, when so directed by the surgeon, who takes his 
position at the hip of the injured side, with a strip of muslin passing 
around his neck and the upper part of the thigh, by means of which 
he raises the head of the bone, when it is brought down to the aceta- 
bulum. The force applied to the pulleys should be gentle and con- 
tinuous, in order to gradually fatigue and extend the muscles; quick 
pulling or jerking upon the cord will add to the difficulties of the 
reduction by stimulating them to stronger contraction. 

The after-treatment consists in keeping the patient in bed with his 
thighs tied together, the injured one being rotated a little outwards, 
for fifteen or twenty days. 



Fig. 495. 



Fig. 496. 




Anatomical relation of sciatic dislocation. 



External appearance of sciatic dislocation. 



2. Sciatic Dislocation. — Sciatic dislocation, or that in which the head 
of the femur rests in the sciatic notch (Fig. 495), is caused by falls or 



552 PARTICULAK DISLOCATIONS. 

blows upon the knees or feet when the thighs are strongly flexed upon 
the abdomen, or the body upon the thighs. 

The capsular ligament is ruptured at its posterior part, the teres 
ligament torn through, and the psoas-magnus, iliacus internus, and 
obturator muscles tensely stretched. 

Symptoms. — The symptoms of this dislocation are similar to those 
of the iliac variety ; the limb will be shortened from half an inch to 
an inch ; the thigh flexed, and the knee projecting in front of the 
opposite one, but not so much as in iliac luxation; the toes rest upon 
the ball of the toe of the other foot (Fig. 496) ; the trochanter is farther 
off from the crest of the ilium, and the head of the bone can be rarely 
felt in its new position ; the thigh is immovable ; and, according to Mr. 
Syme, there is " an arched form of the lumbar part of the spine, 
which cannot be straightened so long as the thigh is straight, or on a 
line with the patient's trunk. When the limb is raised or bent up- 
wards upon the pelvis, the back rests flat upon the bed ; but as soon 
as the limb is allowed to descend, the back becomes arched as before." 

Treatment. — The method of reduction by flexion is the same as in 
the previous case. In the application of the pulleys the patient 
should be placed upon the sound side, and after having arranged the 
extending and counter-extending bands in the manner already pointed 
out, the line of traction should be made across the middle of the oppo- 
site thigh, as seen in Fig. 497, until the muscles are sufficiently 
fatigued to permit the head of the bone to be dislodged from the 

Fig. 497. 




Method of reducing sciatic dislocation with pulleys. 

sciatic notch, when it must be pulled forward to the acetabulum by 
the lac placed around the upper part of the thigh and over the sur- 
geon's neck. 

The after-treatment is the same as in the former case. 

3. Thyroid Dislocation. — This is caused by force applied to the knee 
or foot while the limb is abducted and posterior to the plane of the 
body ; or by heavy weights falling upon the loins or hips while the 
body is bent forwards and the legs widely separated. 

The teres and capsular ligaments (the latter notably upon its inner 
side) are ruptured, and the head of the femur escapes from the coty- 



DISLOCATION OF THE FEMUR. 



553 



loid cavity, and assumes a position upon the external obturator 
muscle over the thyroid foramen, the trochanter looking towards the 
acetabulum (Fig. 498). 

Symptoms. — The thigh is slightly flexed and the body bent forwards 
in consequence of the psoas muscle being put upon the stretch ; the 
limb is lengthened one or two inches, and abducted ; efforts to abduct, 



Fig. 498. 



Fig. 499. 





Thyroid dislocation. 



External appearances of thyroid dislocation. 



extend, and rotate it, are extremely painful ; while the former move- 
ment is impossible ; the foot is generally turned forwards ; the hip is 
flattened, and the head of the femur can be felt at the upper and inner 
surface of the thigh (Fig. 499). 

Diagnosis. — The immobility of the thigh, abduction and lengthening 
of the limb, the turning forwards of the toes, and flattening of the nates 
will so characterize this dislocation as to prevent its being mistaken 
for fracture of the neck of the femur. 

Treatment. — The flexion method may also be applied in this case. 
The thigh is flexed, and, in bringing it down again, instead of rotating 
it outwards as in the former cases, it must be rotated inwards, so as 
to throw the head of the bone towards the acetabulum. It should be 
remarked, however, that, in certain cases recorded, the reduction was 
accomplished by outward rotation. 

Sir A. Cooper's plan with the pulleys is to be conducted in this 
manner : Place the patient on his back ; around the upper part of the 
thigh put an extending band, to which the pulleys are hooked by 



554 



PAETICULAE DISLOCATIONS. 



one of its extremities, the other being attached to a point in the wall 
opposite the injured hip ; the counter-extending band is passed around 

the hips, and through the noose of 
Fig. 500. the extending lac, and drawn over 

to the sound side to be fixed to a 
corresponding point in the opposite 
wall (Fig. 500). 

Force is now applied to the pul- 
leys to extricate the head of the 
femur from the thyroid foramen, 
when the surgeon, passing his hand 
behind the sound limb, seizes the 
ankle of the opposite one and 
draws it towards him, making a 
lever of the first order of the 
injured limb to throw the head of 
the bone towards the acetabulum, 
when the extending pulleys should 
be loosened, and the reduction 
will be effected. 

4. Pubic Dislocation (Fig. 501). 
— This is the rarest of the four 
varieties. It is caused by forces 
acting in the same manner as in 
thyroid luxation; and particularly 
when the limb is thrown very 
much in the rear of the body at the 
time of the injury. 

The capsular ligament is rup- 
tured at its inner and upper por- 
tion, the head of the femur escapes 
and slips upwards upon the pubis outside of the pectineal eminence 
under cover of the psoas magnus and iliacus internus. 

Symptoms. — The limb is shortened about an inch and abducted ; 
the movements of adduction and rotation cannot be executed; the 
toes turn out (Fig. 502) ; the head of the bone can be felt in the groin 
below Poupart's ligament ; the hip is flattened ; and the fold separating 
the femoral and gluteal regions higher up than it is upon the sound side. 
Treatment. — The reduction was effected in a case by Malgaigne in 
the following manner: The thigh was flexed upon the abdomen, 
abducted a little, then rotated inwards, and finally brought down 
adducted. 

In using the pulleys the patient is placed upon his back, the counter- 
extending band is fixed in the wall above the table, and the pulleys to 
an opposite point below it ; then with the thighs widely separated, 
the forces are made to act in opposite directions in the line of the 
axis of the thigh, as seen in Fig. 503. When the head of the bone 
is moved from its position, it may be lifted into its socket by a towel 
passing around the upper part of the thigh and around the neck of 
the surgeon. 




Reduction of thyroid dislocation by pulleys. 



DISLOCATION OF THE FEMUR. 
Fig. 501. Fig. 502. 



555 





Pubic dislocation. 



External appearances of pubic dislocation. 



5. Unusual Dislocations. — The head of the femur has been observed 
to occupy a position between the anterior superior and the anterior 

Fig. 503. 




Mode of reducing pubic dislocation witb pulleys. 

inferior spinous processes, or in front or somewhat behind the latter. 
The symptoms are, shortening of the limb, the toes excessively everted, 
and the head of the bone can be felt in its abnormal position. The 
dislocation may be reduced by flexing the thigh, abducting and rotat- 
ing it inwards, and finally bringing it down adducted ; pressure upon 
the head of the bone with the fingers will contribute to a successful 
result. 

It has also been seen displaced directly downwards ; " the limb was 
lengthened three inches and a half, and was fixed and everted ; the 



556 



PAETICULAE DISLOCATIONS. 



trochanter was sunk ; and the head of the bone close to and on a 
level with the tuberosity of the ischium, where it was capable of 
being moved under the fingers. 

Three other anomalous forms of the dislocation have been recorded, 
viz., upon the body of the ischium between its tuberosity and spine, 
into the lesser sciatic notch, and forwards into the perineum. 

In such cases the reduction may be effected by the flexion method, 
upon the principle already laid down for the other forms of luxations, 
due allowance being made for the differences in anatomical relations 
of the head of the femur. 



Fig. 504. 



Dislocation of the Patella. 

The patella may be dislocated in four directions : outwards, inwards, 
upwards, and upon its own axis. 

Dislocation — 

1. Outwards. 

2. Inwards. 

3. Upwards. 

4. Upon its own axis. 

1. Dislocation outwards. — This is the most frequent variety, and may 
be incomplete or complete, the former being the most common. 

In incomplete luxation the tissues about the joint are not damaged 
to any great extent ; while in the complete variety the capsular liga- 
ment is torn through, and the ligamentum patellar 
more or less lacerated ; sometimes the other ligaments 
about the joint are also concerned in the injury. 

Causes. — The causes are external violence applied 
to the inner edge of the patella, and muscular action. 
It should be noticed that the inner margin of the 
patella is thicker than the outer, and much less pro- 
tected by its corresponding condyle. 

Symptoms. — The knee is more or less flexed and 
immovable ; the inner margin of the patella can be 
felt inclining forwards and outwards when the dislo- 
cation is incomplete, or looking directly forwards 
when complete. In the latter position the vastus 
internus is put upon the stretch, which can be easily 
felt along the inner side of the thigh, while the liga- 
ment of the patella is drawn tense from below out- 
wards, and forms a prominent ridge ; a depression 
will be formed over the condyles from the absence 
of the patella ; and the inner condyle is observed to 
project unnaturally. 
Prognosis. — Usually the luxated bone can be replaced with ease 
and no unfavorable results follow ; there are cases, however, where 
the parts never regain their wonted vigor; so that the patella is 
readily luxated again upon the application of slight force. 




Dislocation of the pa- 
tella outwards. 



DISLOCATION OF THE TIBIA. 



557 



Fig. 505. 




Treatment. — Place the patient upon his back, or, better still, let him 
sit in a chair ; then extend the leg upon the thigh, and flex the thigh 
strongly upon the abdomen, so as to thoroughly relax 
the extensor quadriceps ; then make pressure upon 
the outer border of the patella with the two thumbs, 
when it will resume its natural position. 

When the reduction is effected keep the limb at 
rest for four or five weeks by means of a posterior 
splint bound to it with a roller bandage. 

2. Dislocation inwards. — This injury is caused by 
blows upon the outer margin of the patella. Its 
symptoms will differ from those already noted in 
connection with outward dislocation only so far as 
they must necessarily be modified from the position 
of the patella upon the inner condyle. The treatment 
is the same. 

3. Dislocation upwards. — It results from the ex- 
cessive relaxation of the ligamentum patellae ; it has 
been seen to ascend the thigh as much as three inches. 

The treatment in such a case would be the appli- 
cation of one of the apparatus described in the 
article on fractured patella. 

4. Dislocation of the Patella upon its Axis. — This is a very rare form 
of injury, and results from the same causes as the other varieties. The 
patella may occupy three distinct positions, according to the nature 
and direction of the force causing the dislocation : its inner border 
may repose upon the inter-condyloid space, with the outer border 
projecting forwards ; or the reverse may occur, which is much more 
common ; or the patella may be twisted completely around, so that its 
posterior face shall present anteriorly. 

Symptoms. — The sharp margins of the patella can be felt in the 
median line of the joint, forming a ridge from which two planes slope 
outwards to the borders of the articulation, instead of the naturally 
rounded outline of this part ; the limb is extended and immovable ; 
and the patient suffers severe pain. 

Treatment. — The same method of reduction may be tried in this 
case as in the first; if this should not succeed, as it will not sometimes, 
the leg should be forcibly flexed upon the thigh, and then extended, 
pressure being made at the same time upon the upper and lower mar- 
gins of the patella in opposite directions. 



Dislocation of the pa- 
tella ill-wards. 



Dislocation of the Tibia. 

From the great size and strength of the knee-joint, dislocations of 
the tibia are uncommon, and, when they do occur, are generally in- 
complete. They are caused by violent blows upon the lower part of 
the thigh while the leg is firmly fixed ; or by violence applied to the 
leg while the thigh is fixed ; or, lastly, by violent rotation of the leg 
upon the thigh as an immovable centre, or the reverse. 



558 



PAKTICULAK DISLOCATIONS. 



Fig. 506. 



Dislocation — 

1. Backwards. 

2. Forwards. 

3. Inwards. 

4. Outwards. 

5. By Eotation. 

1 1. Dislocation backwards. — This is the most common of these five 
varieties. If the luxation is complete, the posterior and crucial liga- 
ments are lacerated, and the ligamentum patellae 
and gastrocnemius muscle put upon the stretch, 
as well as the nerves and bloodvessels in the 
popliteal space; the head of the tibia is thrown 
back of the femoral condyles. 

Symptoms. — If the dislocation is complete, the 
limb may be shortened a half or three-quarters 
of an inch, and it is usually in a position of 
extreme extension, though it may be straight or 
flexed; the head of the tibia projects strongly 
in the rear, while the condyles hang over the 
patella in front, causing a marked depression 
below them, across which the tendon of the ex- 
tensor quadriceps is tensely stretched. 

Prognosis. — When the injury to the joint is 
inconsiderable, and the dislocation has been 
promptly reduced, the patient usually makes a 
speedy recovery ; on the other hand, there are 
cases in which months elapse before the func- 
tions of the limb are restored. In very severe 
injury to the articulation, excessive inflammation, with suppuration, 
sometimes follows, often requiring amputation or resection. A dis- 
position to reluxation, and an inability to keep the leg straight in the 
erect posture, have also been noted as an occasional result of this 
dislocation. 

Treatment. — The dislocation may.be reduced by making extension 
and counter-extension from the ankle and thigh, or, better still, from 
the perineum, while the surgeon presses the bones in opposite direc- 
tions to the displacement. Sometimes alternate flexion and extension, 
with slight rotation of the leg, will accomplish the object at once. 

After-treatment. — The patient should be kept in his bed five or six 
weeks, with the limb in a straight position, and inflammatory action 
controlled by antiphlogistics; afterwards, gentle movements should be 
impressed upon the joint, to prevent anchylosis. 

2. Dislocation forwards. — This differs from the preceding variety 
in the head of the tibia being thrown in front of the condyles, instead 
of behind, forming a prominence anteriorly, upon the top of which 
the patella reposes. The limb is shortened from one to four inches 
if the luxation is complete, and, viewed from behind, the leg appears 
unnaturally short, while a front view conveys the impression that the 




Dislocation of the head of 
the tibia backwards. 



DISLOCATION" OF THE TIBIA 



559 



thigh is lengthened. The movements are not so difficult as in the 
previous case. 

The treatment is the same as iu dislocation backwards. 



Fig. 507. 



Fig. 508. 





Dislocation forwards. 



Incomplete dislocation outwards. 



Fig. 509. 



3. Dislocation outwards. — This is almost always partial. Malgaigne 
has reported one case where the head of the tibia passed to the outside 
of the external condyle, and rose above the level of 
its articular surface. 

Symptoms. — The limb presents a twisted appear- 
ance, and the leg is slightly flexed and rotated on 
its axis; the joint is increased in breadth, the tibia 
projecting externally, forming a tumor upon the 
outside of the articulation ; the inner femoral con- 
dyle is equally prominent upon the inner aspect of 
the limb ; and the patella is pushed outwards. 

The treatment does not differ from that of pos- 
terior luxation. 

4. Dislocation inwards. — This variety of disloca- 
tion is the reverse of the preceding; the head of 
the tibia is displaced inwards, so that the inner 
condyle of the femur rests upon the centre of its 
articulating surface. The symptoms and treatment 
will be the same as in luxation outwards, except 
so far as these must necessarily vary from the op- 
posite position of the head of the tibia. 

5. Dislocation by Rotation. — This injury occurs 
when the leg is twisted inwards or outwards so as to throw one of the 
femoral condyles from its articulating facet, while the other remains 
in its natural position. 

Symptoms. — Eotation of the leg inwards or outwards, according as 
its inner or outer articular facet is displaced ; it is slightly flexed ; and 
the joint is altered in shape. 




Incomplete dislocation 
inwards. 



560 PARTICULAR DISLOCATIONS. 

Treatment. — Extension and pressure upon the head of the tibia, with 
rotation of the leg in a direction opposite that of the displacement. 

Dislocation of the Semilunar Cartilages. 

Dislocation of the semilunar cartilages results from a sudden twist- 
ing of the knee-joint by striking the toes against an obstacle, or 
making a false step. One of the cartilages is thereby displaced, and, 
in some cases, may be almost entirely separated from its connection 
with the articular surface of the tibia, and become wedged between 
the joint-surfaces. 

Symptoms. — The patient is aware that something has given way in 
the knee-joint, and he finds that he can neither support the weight of 
the body upon the limb nor fully extend the leg ; he suffers severe 
pain in the knee, and feels sick and faint ; and after the lapse of a 
few hours the articulation becomes swollen and tender. 

Treatment. — The cartilage may be restored to its natural position 
by placing the patient upon his back, then raising the limb from the 
bed, let the surgeon support the ham upon his left arm, while he 
grasps the ankle in his .left hand, and flexes the leg, rotating it at the 
same time outwards ; then let him suddenly extend it. 

Mr. Fergusson relates the case of a patient who could effect a re- 
placement of the cartilage by pointing the toes outwards as much as 
possible, and then lifting the foot forward, with the opposite foot 
behind the tendo-Achillis; and Sir A. Cooper tells of a person who 
accomplished the same object by bending the thigh inwards, and draw- 
ing the foot outwards, while he sat upon the floor. 

In order to support the joint, and thus prevent a renewal of the 
luxation, the patient should wear an elastic knee-cap. 

Dislocation of the Fibula. 

I. Dislocation of the Upper Extremity — 

1. Forwards. 

2. Backwards. 

II. Lower Extremity — 
Backwards. 

1. Dislocation of the Upper Extremity of the Fibula. 1. Dislocation 
forwards. — There are but three recorded examples of this dislocation, 
which results from muscular action, or direct force applied to the 
upper extremity of the fibula. It is recognized by the tumor caused 
by the displaced head of the bone, near the tubercle of the tibia ; the 
tendon of the biceps flexor will be drawn forwards out of its normal 
situation; and marked depression will be observed below and upon 
the outer side of the knee. 

In the treatment of this luxation pressure must be made upon the 
head of the fibula backwards to force it into its natural position. 

2. Dislocation backwards. — This is caused in the same manner as 
forward luxation. In a case reported by Dubreuil the head of the 
fibula formed a tumor posteriorly ; the foot was drawn outwards, and 
the whole outside of the limb was cold and numb. 



DISLOCATION OF THE FOOT 



561 



The reduction was effected by flexing the leg moderately, and press- 
ing upon the head of the fibula from behind forward. 

II. Dislocation of the Lower Extremity of the Fibula. Dis- 
location backwards. — The only case of this variety of luxation is 
recorded by Nelaton. It was caused by the passage of a wheel over 
the upper part of the leg. The lower end of the fibula was forced 
backwards so as to be almost in contact with the tendo-Achillis ; the 
outer face of the astragalus, uncovered by the external malleolus, 
could be distinctly felt; the foot was in a natural position. The 
patient presented himself at the hospital thirty days after the accident, 
and it was not deemed advisable to make any efforts at reduction. 



Dislocation of the Foot (Astragalus upon the Tibia and 

Fibula). 

The astragalus may be dislocated upon the bones of the leg in the 
direction indicated in the following table : — 

Dislocation — 

1. Forwards. 

2. Backwards. 

3. Inwards. 

4. Outwards. 

5. Upwards. 

6. By Eotation. 

1. Dislocation forwards (Fig. 510). — This is the most uncommon of 
the five varieties of luxation affecting the ankle-joint. It is caused by 
falls upon the heel while the foot is strongly flexed. 

The ligaments about the articulation are ruptured, and the astra- 
galus is forced forwards in front of the lower end of the tibia. 



Fig. 510. 



Fig. 511. 





Dislocation of the foot forwards. 



Symptoms. — The symptoms are : Lengthening of the foot in front 
of the malleoli, and a corresponding shortening of the heel, which 
forms, with the posterior surface of the leg, a straight line; the leg is 
36 



562 



PAKTICULAR DISLOCATIONS. 



somewhat shorter than the other, and the malleoli approach nearer 
the sole of the foot and heel (Fig. 511). 

Treatment. — For accomplishing the reduction, the patient should be 
placed upon the injured side, with the thigh raised perpendicular to 
the trunk, and the leg flexed at a right angle with the thigh, so that 
the muscles of the calf of the leg shall be relaxed. An assistant sup- 
ports the thigh, and makes counter-extension, while the surgeon 
grasps the foot in his hands and draws it downwards; at the same time 
he endeavors to carry it backwards, in order to place the astragalus 
beneath the tibia. 

The limb may be subsequently semiflexed, and placed upon a 
double-inclined plane, with a compress just above the heel. 

2. Dislocation backwards (Fig. 512). — This dislocation is exactly the 
reverse of the preceding. It is caused by violent extension of the 
foot, as when its anterior part is firmly held while the body is thrown 
backwards. The lower extremity of the fibula is commonly broken, 
and the ligaments considerably lacerated. It may be complete or in- 
complete. 



Fig. 512. 



Fig. 513. 





Dislocation of the foot backwards. 



Symptoms. — The anterior part of the foot will be shortened, while 
the heel is elongated, and the tendo-Achillis prominent. The astra- 
galus can be distinctly felt behind the ankle, and the end of the tibia 
in front of it ; and the toes are depressed with a corresponding eleva- 
tion of the heel (Fig. 513). 

Treatment. — The reduction can be easily accomplished by extension 
in the manner directed for dislocation forwards ; there is, however, 
greater difficulty encountered in maintaining it, as the bones have a 
constant disposition to slip from contact with each other. 

Dupuytren recommends that his splint for fractured fibula should 
be applied after the reduction, and the limb laid upon its side in a 
semiflexed position; and Malgaigne employed in one case success- 
fully a boot-shaped splint of plaster of Paris. 

Should there not be any contra-indication present, the starch 



"DISLOCATION OF THE FOOT, 



563 



bandage applied to the foot and leg, would be serviceable; while in 
those cases where there is much swelling and inflammation, the leg 
may be placed in an ordinary fracture-box, with the foot secured to 
the footboard, the forward tendency of the tibia being overcome by 
compresses placed in front of, and above the ankle. 

3. Dislocation inwards (Fig. 514). — In this luxation, the astragalus is 
either completely displaced inwards by slipping horizontally inwards 
from the articular surface of the 

tibia, or it rotates upon its axis Fi S- 514 « 

so as to place its inner and 
upper margin against the mid- 
dle portion of that surface in 
such a manner that its superior 
surface looks outwards. 

The tibio-tarsal ligaments are 
usually ruptured, and the inner 
malleolus fractured; sometimes 
they are entire, and in that case 
the fibula will give way above 
the malleolus, the lower frag- 
ment remaining in connection 
with the tarsus; in other in- 
stances the tibio-tarsal lisraments 
will remain untorn, and both 
malleoli are fractured. 

Causes. — Falls upon the foot, 
forcing it into an extreme de- 
gree of abduction ; it is some- 
times the result of direct vio- 
lence, as the passage of a vehi- 
cle over the ankle. 

Symptoms. — The foot is turned 
inwards, and the external mal- 
leolus forms a remarkable pro- 
minence upon the outer ankle ; 
and the astragalus can be easily 
felt beneath the inner malleo- 
lus. 

Prognosis. — This injury can only be produced by great force, which 
renders the prognosis always serious. It is often followed bv severe 
inflammation and profuse suppuration, resulting in anchylosis. 

Treatment. — The reduction is accomplished in the same general 
manner as previously described for luxation forward. The extension 
should first be made in the direction of the displacement, and when 
the astragalus begins to move in the axis of the leg, the surgeon at 
the same time abducts the foot, to throw the astragalus beneath the 
articulating surface of the tibia. 

In both of the lateral dislocations it may be necessary to apply 
more force than can be effected with the hands, when recourse should 
be had to the pulleys in the manner shown in Fig. 515. 




Dislocation of the foot inwards. 



564 



PAKTICULAK DISLOCATIONS, 



The after-treatment consists in applying two side-splints of gutta- 
percha, neatly moulded to the foot and ankle, so that these parts may 



Fig. 515. 




Keduction of dislocation of the foot with pulleys. 

be thoroughly supported; the inflammatory action is to be combated 
by appropriate remedies. 

If fracture of the fibula complicates the dislocation, the splint of 
Dupuytren should be employed. 

Fig. 516. 




Dislocation of the foot outwards. 



4. Dislocation outwards (Fig. 516). — It is the most common luxation of 
the ankle ; the astragalus rotates inwards, so that its outer and upper 



DISLOCATION OF THE TARSUS. 565 

border is in contact with the articular surface of the tibia, and its 
superior plane looks inwards. This peculiar position of the astragalus 
cannot be assumed without a rupture of the tibio-tarsal ligaments and 
a fracture of the fibula above the joint. There is also often found an 
oblique fracture upwards and outwards through the outer margin of 
the articular surface of the tibia. 

Causes. — The causes of this luxation are falls upon the sole of the 
foot when it is somewhat abducted ; and direct violence. 

Symptoms. — The foot is abducted and the inner malleolus produces 
a protuberance beneath the skin upon the inner side of the foot ; the 
inner margin of the foot rests upon the ground while its outer border 
is turned upwards ; there is a depression above the outer malleolus 
over the seat of fracture where crepitus may be elicited; and the 
astragalus can be easily perceived beneath the external malleolus. 

Treatment. — Extension should be made from the foot in the manner 
we have already pointed out; and when the reduction is effected 
.Dupuytren's splint must be applied ; or a gutta-percha splint, or a tin 
case, may be employed which shall perfectly sustain the foot and 
ankle. An important point in applying dressings in these dislocations 
is that in order that there may be no constriction of the parts by inflam- 
matory swelling, the splints and bandages should, at first, be put on 
loosely. 

5. Dislocation upwards. — The astragalus may be forced upwards 
between the tibia and fibula, the latter bone being in such a case 
always broken at its lower extremity. 

Symptoms. — The symptoms are the following : The distance between 
the malleoli is increased, which gives the appearance of great breadth 
to the ankle ; the inner malleolus projects nearly to a level with the 
sole of the foot, the opposite one being raised, sometimes as much as 
two or three inches ; and the leg is shortened. 

Causes. — A fall upon the sole of the foot in such a manner that the 
weight of the body is transmitted to the instep vertically. 

Treatment. — The reduction is often difficult ; it is effected by ex- 
tension and counter-extension ; the leg should then be placed in a 
fracture-box, and antiphlogistic remedies employed until the inflam- 
mation has subsided, when a pasteboard splint may be substituted 
for it. 

6. Dislocation by rotation. — Huguier records a case where the foot 
was violently twisted outwards, while the leg was held firmly, so that 
the heel was nearly brought under the inner malleolus, and the toes 
rotated outwards through a half of a circle. 

Treatment. — Extension and rotation of the foot inwards. 

Dislocation of the Tarsus. 

I. Astragalus. 

1. Forwards. 

2. Backwards. 

3. Inwards. 

4. Outwards. 



566 



PARTICULAR DISLOCATIONS. 



II. Os Calcis and Scaphoid upon the Astragalus. 

1. Backwards. 

2. Inwards. 

3. Outwards. 

III. Cuboid and Scaphoid upon the Os Calcis and Astragalus. 

Forwards and upwards. 

IV. Scaphoid. 

Forwards. 
Y. Cuneiform Bones. 
Forwards. 

1. Dislocation of the Astragalus. — This may occur forwards, back- 
wards, outwards, and inwards, and it either retains its horizontal 
position, or may be more or less rotated upon its axis or even com- 
pletely reversed, so that its inferior surface will look directly upwards. 
a. Dislocation forwards is caused by a fall upon the foot in a position 

of extension ; the astragalus is forced upon 
Fi g- 517. its dorsum, producing a marked promi- 

nence over which the skin will be tensely 
stretched; the leg is shortened, and the 
malleoli approximated nearer to the bot- 
tom of the foot. 

b. Dislocation backwards is extremely 
rare ; and is caused in the same manner as 
the preceding, only the foot is in forced 
flexion at the time of the application of the 
injury: the astragalus takes a position 
posterior to the joint under the tendo- 
Achillis, which is pushed backwards, and 
may be readily perceived in its new posi- 
tion ; the instep is shortened, and the heel 
elongated. 

c. Dislocations inwards and outwards 
(Fig. 517) are produced by the force acting 
upon the foot when it is abducted or ad- 
ducted; they are mere varieties of the 
luxation forwards. 

These injuries are often compound, and 
attended with more or less laceration and 
bruising of the soft tissues about the joint. 
Treatment. — In simple dislocation of the astragalus, efforts should 
be made to effect its reduction. The patient should be thoroughly 
anaesthetized, and the thigh bent at right angles with the abdomen, 
and the leg upon the thigh ; an assistant should then make counter- 
extension from the lower part of the thigh, while another takes hold 
of the heel and instep, or, what is better, applies an extending lac and 
firmly draws the foot downwards ; the surgeon, standing by the limb, 
endeavors to press the astragalus upwards and backwards into its 
place with his thumbs or his knee; but if the bone has an inclination 
to either side, the pressure should be exercised first in such a manner 




Dislocation of the astragalus 
outwards. 



DISLOCATION OF THE TARSUS, 



567 



Fie. 518. 



that the astragalus may assume the position it takes in forward dislo- 
cation. While the pressure is being made, the foot should be adducted 
or abducted, according as the one or other of these positions will per- 
mit the bone to slip back beneath the tibia. Should reduction be 
impossible, it is believed by the majority 
of surgeons that, in order to save the 
foot, the astragalus ought to be removed 
at once. 

When there is a wound present, and 
the bone can be felt to be entirely sepa- 
rated from its articular connections (Fig. 
518 ), it must be removed immediately, as 
it then acts, as any foreign body would, in 
causing inflammation and suppuration 
of the joint, which will lead most surely ^ 
to amputation of the foot; this course is 
altogether the safest one, as in a number 
of the recorded cases in which the opera- 
tion had been performed the patients 
recovered with tolerably good limbs. 
Nelaton'a opinion is that in simple dis- 
location, even of the astragalus, the re- 
duction ought not to be attempted, but 
immediate resection had recourse to. 
This view is in opposition to the prac- 
tice of the majority of surgeons; and 
the instances of successful reduction on 
record are sufficiently numerous to in- 
duce the surgeon, in all cases of simple dislocation, to try manipulation 
before resorting to the knife. 

The after-treatment consists in giving the leg and foot efficient 
support with splints, and to meet the inflammation with appropriate 
antiphlogistics : when suppuration begins, the pus should have a free 
issue exteriorly. 

2. Dislocation of the Os Calcis and Scaphoid upon the Astragalus. — 
This dislocation may occur backwards, inwards, and outwards; the 
latter bone retaining its articular connections with the tibia. In dis- 
location backwards, the heel is elongated, and the foot in front of the 
malleoli correspondingly shortened ; the head of the astragalus can be 
felt under the skin upon the top of the foot, lying upon the scaphoid 
and cuneiform bones. 

The luxation inwards is marked by the prominence of the head of 
the astragalus upon the outer side of the instep ; the foot is usually 
in a position of adduction, with its external border resting upon the 
ground, while the toes turn inwards and the heel outwards. 

The astragalo-calcanean, peroneo-calcanean, and tibio-calcanean liga- 
ments are more or less torn, and usually also the soft parts about the 
foot, particularly over the head of the astragalus, which may perforate 
the skin and be visible upon the side of the foot. 

Dislocation outwards is the reverse of the preceding. The head of 




Compound dislocation of the astragalus 
iuwards. 



568 PARTICULAR DISLOCATIONS. 

the astragalus will form a prominence upon the inner border of the 
foot, which is forcibly abducted and sometimes greatly rotated upon 
the leg; when the os calcis is completely separated from the astragalus, 
it will be elevated by the side of the fibula, and the leg will be short- 
ened. The injury is almost always compound, and the end of the 
fibula and head of the astragalus will often be found projecting through 
the wound upon the inner side of the foot. 

Treatment. — The reduction should be attempted by making exten- 
sion from the foot, and pressure upon the bones in a direction opposite 
the displacement ; it is, however, often difficult, if not impossible, and 
may then demand either resection or amputation. 

3. Dislocation of the Cuboid and Scaphoid upon the Os Calcis and 
Astragalus. — In the case recorded by Liston of this form of dislocation 
the cuboid and scaphoid were thrown upwards and forwards upon the 
os calcis and astragalus, caused by a heavy stone falling upon the foot, 
which was twisted in such a manner as to resemble club-foot. The 
reduction was effected by making extension from the forepart of the 
foot, and the patient was cured in five weeks. 

4. Dislocation of the Scaphoid. — This has been observed to occur in 
several cases ; the bone being detached from its connections with the 
cuneiform only, in one instance, and in the others from both the astra- 
galus and cuneiform bones, and displaced forwards. 

Treatment. — Pressure upon the scaphoid with the thumb, while the 
forepart of the foot is bent downwards. 

5. Dislocation of the Cuneiform Bones. — The three cuneiform bones 
together may suffer in complete luxation forwards ; or, what is more 
common, the internal cuneiform may be completely displaced, and 
thrown forwards and upwards upon the tarsus along with the meta- 
tarsal bones. The symptoms are foreshortening of the foot, the plantar 
surface of which is convex, both antero-posteriorly and transversely, 
and turned inwards ; the proximal ends of the metatarsal bones form 
a ridge upon the top of the foot. 

Treatment. — Extension from forepart of the foot with pressure upon 
the displaced bones. 

Dislocation of the Metatarsal Bones. 

The metatarsal bones may be dislocated separately in any direction 
by crushing force being brought to bear upon the foot; or all of them 
together may be thrown forwards and upwards upon the tarsus ; the 
luxation in either case may be complete or incomplete. In the former 
case the foot will be shortened, and a ridge will be formed upon the 
top of- the foot by the proximal extremities of the displaced bones ; 
and the bottom of the foot will present a convex instead of the natu- 
ral concave outline. When a single bone is displaced, its upper extre- 
mity will cause a recognizable deformity at the point of injury. 

Treatment. — Extension from the forepart of the foot, and counter- 
extension from the lower portion of the leg above the ankle, combined 
with pressure upon the dislocated bones. 



DISLOCATION OF THE PHALANGES OF THE TOES. 569 



Dislocation of the Phalanges of the Toes. 

Dislocation of the phalanges of the toes may occur in any direction, 
and be complete or incomplete. It is less common than that of the 
phalanges of the fingers, and more often compound. 

The injury is caused by direct violence applied to the toes. Its 
treatment should be conducted upon the same principles laid down for 
dislocation of the phalanges of the fingers already explained. 



PART V. 

ru.fi MINOR OPERATIONS OF SURGERY 



CHAPTER I. 

RUBEFACTION. 

R U BE faction, from ruber, "red," and facio, "I make," is the result 
of the action of that class of remedial agents called rubefacients, which 
have the property of causing redness, pain, and slight swelling of the 
skin. 

The number of substances included in this class is quite large ; be- 
sides, there are several mechanical processes that have been employed 
to obtain this modification of the integuments. 

The rubefacients proper, when retained too long upon the surface, 
produce vesication ; while the mechanical processes under ordinary 
circumstances determine rubefaction only ; however, should the fric- 
tion be violent, as occurs in the rapid passage of a rope through the 
clenched hand, for instance, true vesication follows ; the same result 
may also accompany energetic shampooing. 

All vesicants are necessarily rubefacients; and may often be used 
as such with advantage by simply regulating the period of their con- 
tact with the skin. 

A peculiar mode of producing rubefaction for the cure of neuralgia, 
chronic rheumatism, and other painful and long-standing diseases has 
been in vogue in China and other eastern countries from time imme- 
morial. The way I have seen it performed is this : The patient is 
stripped naked, and the operator, generally a barber, commences by 
striking the skin over the painful parts lightly with the tips of his 
fingers ; and as it becomes accustomed to the new impression, and also 
somewhat numbed, the palms of the hands are substituted for the fin- 
gers, and the blows fall quicker and heavier, in regular rhythm, until 
the affected parts are quite red and tender. 

The Hindoo operation of shampooing is also a very ancient counter- 
irritant process, and consists in the forcible pressure of the muscles 
with the hands, flagellations, and the crackings of the various joints. 

The massage is sometimes of real utility in chronic affections of the 
joints, chronic rheumatism, false anchylosis, and sprains. 

All these mechanical means will, however, be of limited utility, as 
possibly their only action is to blunt the sensibility of the skin by the 
repetitions of monotonous impressions upon the nerves ; though the 



RUBEFACTIOX. 571 

counter-irritant effect of the determination of fluids to the parts, and 
the stimulation of the capillary circulation may add to their beneficial 
influence. 

Of all the mechanical methods, friction is most frequently used in 
the treatment of surgical disease. It is of two kinds, dry and moist; 
the former being accomplished with the palms of the hands, coarse 
towels, or stiff brushes ; and the latter with a piece of flannel, moist- 
ened with stimulating liquids. 

This plan is indicated in the same class of cases as massage, care 
being taken that the continuity of the cuticle be not disturbed. 

Kubefaction is most generally produced by the use of sinapisms, a 
name given to a pasty material composed principally of mustard, and 
spread upon cotton cloth for convenience of application. 

Mustard, the flour of the seeds of the Sinapis nigra, depends for its 
rubefacient properties upon a volatile oil developed by the reaction 
between two of its constituents, myrosine and myronic acid, in the 
presence of water, the temperature of which, to obtain the most active 
cataplasm, should be inside of 212° Fahr. 

Some persons are in the habit of employing vinegar instead of water, 
but the practice is wrong, as the former fluid materially interferes with 
the production of the volatile oil. Strong acids and the alkalies have 
the same effect. 

If it is desirable to increase the activity of the mustard, red pepper, 
garlic, or cantharides in powder, may be added to it; on the other hand, 
to diminish its activity it may be incorporated with powdered flaxseed 
or bread crumb. 

The time required for a sinapism to produce a rubefacient will 
depend upon the thickness and susceptibility of the skin, and the age 
of the patient. A thin skin with its nutritive processes going on 
actively, will show the effects of a rubefacient in a much shorter time 
than one in which the contrary conditions obtain, as in cases of 
paralysis, where several hours will elapse before any action is mani- 
fested, if it is manifested at all. It sometimes happens, however, in 
these paralytic patients that a sinapism may remain on for a long time ; 
and when it is raised, no effect will be observed upon the skin, nor 
will the person complain of any pain or sensation in the part, yet at 
the end of some days vesication and even mortification may result. 

As a general rule it may be stated that less time is required to pro- 
duce rubefaction in children than in women, and in these than in men. 

Under ordinary circumstances, sinapisms made with cool water 
should not be permitted to remain in contact with the skin longer than 
one hoar, though in the special cases mentioned above a much longer 
or a much shorter period may be proper. 

The best guide, in all cases, as to the proper time, where the nervous 
system is in its normal state, is the sensations of the patients ; though 
the redness of the skin will be of some assistance, as it enables us to 
judge of the degree of rubefaction. 

After the desired effect has been produced the sinapisms should be 
promptly removed, and the surface of the skin cleansed by allowing 
a little warm water to flow upon it. If there is much pain, a small 



572 KUBEFACTION". 

quantity of ether may be allowed to fall upon the parts, guttatim, 
which will assuage it immediately. Any soreness or tenderness will 
be best met by the application of lint dipped in glycerine, oil of sweet 
almonds, or olive oil. Ointments containing the ordinary narcotics, 
opium, belladonna, or stramonium will answer the same purpose. 

When the continuous counter-irritant effects of a sinapism are re- 
quired, it should be moved from point to point every few minutes to 
avoid too much action in one place, but yet not over too great an 
extent of surface; otherwise, unpleasant constitutional disturbance 
may ensue. 

Under certain circumstances, it may be important to obtain rube- 
faction speedily ; then the volatile oil of mustard dissolved in alcohol 
in the proportion of one part by weight of the former to twenty of 
the latter may be used, rubbing it upon the skin with a piece of flannel ; 
its effects will be produced in three or four minutes. Other articles, 
as ammonia, will produce the same effects. 

Urtication is a sort of rubefaction produced by striking the skin 
with a bunch of nettles ( Urtica dioitica), or rubbing upon it an oint- 
ment containing the common cowhage (Dolichos pruriens). 

In narcotic poisoning, flagellation with nettles was formerly em- 
ployed ; but its use is now entirely abandoned. 

Sinapisms justly occupy a high position in the esteem of the people 
at large as a remedy of superior merit in numerous ailments, while 
the profession is equally as decided upon their virtues in numerous 
diseases coming daily under notice. 

They are employed as a general excitant in syncopal attacks, 
shock, or severe concussion from injuries, and in nervous depression ; 
as a local excitant to recall retrocedent eruptions and inflammations, 
as in measles, smallpox, gout, and rheumatism ; as a counter-irritant 
in inflammatory diseases of the brain, and of the organs contained 
within the thorax and abdomen ; and to relieve various painful affec- 
tions from other sources. 

Sinapisms form the favorite and safest counter-irritant in the dis- 
eases of children, when blisters are contra-indicated by the debility of 
the patient, or the extreme sensibility of the skin. We should be 
careful in these cases not to let them remain on the person of the 
child until constitutional disturbance results from the local stimula- 
tion, and thereby do more injury than can be counterbalanced by the 
good done by their counter-irritant effect. 

For speedy rubefaction Dr. Corrigan recommends the instrument 
seen in Fisr. 519. It consists of a thick iron-wire shank, about two 

inches long, inserted in a small 
Fig. 519. wooden handle, having on its 

extremity, which is slightly 
curved, a disk or button of 
iron, a quarter of an inch 
thick, and half an inch in 
diameter. 

To use the instrument, it 

Corngan's button cautery. , ' 

is necessary to hold the button 
over the flame of a small spirit-lamp, keeping the forefinger of the 




VESICATION. 573 

hand holding the instrument at the distance of about half an inch 
from the button. As soon as the finger feels uncomfortably hot, the 
instrument is ready for use; and the time required for heating it to 
this degree is only about a quarter of a minute. It is applied as 
quickly as possible, the skin being tipped successively at intervals of 
half an inch over the affected part as lightly and as rapidly as pos- 
sible. 



CHAPTER II. 

VESICATION. 

Vesication, from vesica, a "bladder," or "blister," is the action of 
that class of remedies called vesicants, which cause inflammation of 
the skin, and an effusion of serum beneath the cuticle, forming little 
bladders or vesicles. 

The local inflammatory action, with its accompanying derivative 
effects and constitutional excitation, does not constitute the whole 
therapeutical influence of vesicants ; for along with this, there is an 
effusion of fibrinous serosity from the blood, which confers upon them 
an important value as depletants. 

The extent to which this effusion sometimes takes place was shown 
in a case which came under my care some months since. The patient 
had an ordinary blister applied upon the abdomen, over night; and 
the following morning it was removed, displaying a large vesicle filled 
with a pale, yellowish, jelly-like mass, a quarter of an inch in thick- 
ness, which, with every movement of the patient, presented that tre- 
mulous motion peculiar to jellies. Its removal was followed, in a few 
hours, by another layer of the same material, though thinner, and* it 
was some days before the serosity ceased to concrete spontaneously 
upon the blistered surface. 

Some of the rubefacients already spoken of will vesicate if kept 
upon the surface a sufficient period, yet there are other articles more 
especially employed for this peculiar purpose, and they are drawn 
from all three of the kingdoms of nature. 

Of the physical agents heat has been employed as a vesicant in 
several ways ; yet it is not so readily manageable as to recommend 
itself as a general method ; for though its action is speedy and cer- 
tain, the fear of its causing an eschar, and the pain of its application, 
will restrict its use to a very limited number of cases. 

A compress folded several times, then dipped into boiling water, 
and applied to the skin, will produce quick vesication. 

The head of a hammer, or the fiat cautery iron, held for a few 
moments in boiling water and laid upon the surface, will also give 
rise to the same result. 

Sir Anthony Carlisle laid over the skin a wet cloth, and passed 
over it a flat cautery-iron, brought to a dull red heat. 



574 VESICATION. 

It has been recommended in collapse, attended with great insensi- 
bility of the skin, to produce a blister immediately by placing a piece 
of tissue-paper, saturated with alcohol or spirits of turpentine upon 
the surface, and set fire to it. A jet of steam, from the spout of a 
vessel containing boiling water, has been suggested with a . similar 
view. 

We have already spoken, at page 69, of the liquor ammonise of the 
Pharmacopoeia as a vesicant, and its mode of application. A watch- 
glass case will answer the same purpose as the lid of a box there 
mentioned. Place a round piece of muslin, a little smaller than the 
glass, and saturated with liquor ammonia, upon the skin, previously 
cleared of hair, and then cover it with the crystal. In half a minute 
or a minute a red areola will be seen to surround the margin of the 
glass, when it should be removed, and an appropriate dressing applied 
to the blister. 

When the ammonia is incorporated with fatty matters, the vesicat- 
ing ammoniacal ointment of Dr. Gondret is formed. "The amended 
formula is as follows : Take of lard 32 parts ; oil of sweet almonds 
2 parts ; melt them together by the gentle heat of a candle or lamp, 
and pour the mixture into a bottle with a wide mouth. Then add 
17 parts of solution of ammonia of 25°, and mix, with continued agi- 
tation, until the whole is cold. The ointment must be preserved in a 
bottle with a ground stopper, and kept in a cool place." — U. S. D. 

This ointment is applied by spreading it upon muslin, and when 
freshly prepared it will vesicate in from five to ten minutes. The 
application will be more accurate, and the ammonia prevented from 
evaporating, by using a shallow pill-box lid instead of the muslin. 

It will be a useful precaution, in using these ammoniacal mixtures, 
to protect the parts surrounding the place to be blistered, by adhesive 
plaster, which may be laid over them, having a hole of the proper size 
cut into it, to expose that portion of the skin to which the vesicant is 
to be applied. 

The vegetable kingdom furnishes from the two orders, Ranuncu- 
laceae and Euphorbiacese, many active vesicants, among which are 
several species of the Ranunculus, or crowfoot, which, before the intro- 
duction of the Spanish flies into use, were much employed as vesicants. 

The knowledge of the powerful rubefacient and epispastic proper- 
ties of these plants may, on occasions, be serviceable to the country 
practitioner. Nearly the same qualities are possessed by the bulb of 
the Indian turnip. 

Mezereon-bark is also a slow vesicant, and is frequently used by 
German surgeons for this purpose. For the application of this, Che- 
lius directs that "a piece of the bark an inch and a half long and the 
same wide should be soaked eight or ten hours in vinegar or water, 
after which it is to be applied with its smooth surface next to the skin, 
generally upon the arm, at the insertion of the deltoid muscle, and 
covered with a piece of oiled silk, compress, and roller, to keep it 
close. After ten or twelve hours, when the bandage is removed, if 
the skin be sufficiently inflamed, a piece of oiled silk is to be applied 
on the inflamed part and fastened with compress and bandage ; but if 



VESICATION. 575 

the first application Lave not been effective, a second piece of the bark 
must be applied. About the second or third day a new piece of bark 
is put on, the skin rises, and a serous fluid exudes. The part must 
be cleansed daily with warm water or milk; and if the inflammation 
be very great, it must be rubbed with warm milk and bound up with 
some mild ointment." 

Croton oil, obtained by expression of the seeds of the Croton tig- 
lium, is an excellent vesicant. Its operation is not at all painful, nor 
actively depletive, but mildly counter-irritant. For these reasons it 
recommends itself highly to the notice of the practitioner in those 
cases of disease where long-continued counter-irritation has been found 
useful. The oil may be applied to a large extent of surface, without 
any fear from constitutional disturbance or of its manifesting its spe- 
cific action upon the intestines. 

It may be used pure, or diluted in various degrees with olive oil, 
and rubbed into the skin with a piece of flannel, or the point of the 
finger protected with oiled silk. 

Two or three applications will be necessary to obtain the desired 
result, which consists in the production of a crop of vesicles, at first 
containing a clear fluid, but in a little while this becomes opaque and 
yellowish. The skin beneath the vesicles is changed to a red color, 
accompanied with a sensation of stinging and swelling of the parts. 

After two or three days the pustules dry up, the irritation disap- 
pears, and new cuticle is formed. 

The application of the oil in this manner requires two days or more 
to produce the effect, in consequence of the escape of crotonic acid, 
upon which its efficacy depends. To avoid this, Bouchardat suggested 
to M. Chomel a formula containing one part of the oil incorporated 
with four parts of lead plaster, spread upon linen in the same manner 
as adhesive plaster. These proportions may, however, be varied 
according to circumstances. This plaster, worn upon the person 
twenty-four hours, will produce an abundant eruption of vesicles. 

In employing preparations containing croton oil, care should be 
taken that the patient's hands do not come in contact with the parts, 
else some of the oil will be transferred to the skin of the eyelids, 
scrotum, or other localities, and thus produce swelling of them, and 
an annoying sensation of burning. 

The application of a dressing of glycerine or cold water will relieve 
these unpleasant accidents. 

The animal kingdom supplies from among the coleopterous insects 
several vesicating species, of which only two — the cantharis vesica- 
toria, or Spanish fly, and the cantharis vittata, or potato-fly — have 
been introduced into the Pharmacopoeia of the United States, and it 
is of these that our officinal preparations are made. 

The cerate of Spanish flies (Ceratum cantharidis) is the common 
blistering plaster of the shops; it should be spread upon leather, 
though linen, or even paper, will answer the purpose when that is not 
to be had. In applying the plaster, the skin is to be cleansed of hairs 
and well rubbed with vinegar or oil, which will materially facilitate 
the action of the vesicant. It is recommended that the surface of the 



576 VESICATION. 

blister be covered with oil or a layer of simple cerate, oiled paper, or 7 
what is better, a piece of very thin tissue-paper or gauze. These 
interposed substances will prevent the particles of the flies sticking 
to the skin and producing strangury. With the same view ; the late 
Br. Joseph Hartshorne was in the habit, in cases where he appre- 
hended such a result, of directing four grains of opium and twenty of 
camphor to be mixed with the cerate of a blister of large size ; an 
ethereal solution of camphor may also be used, brushed over the sur- 
face of the plaster before it is applied. 

The decoction of the uva ursi, in the dose of a wineglassful every 
hour during the application of the epispastic, is also highly recom- 
mended as a preventive of strangury. 

The time the blister should be kept on depends upon the object 
had in view, the general sensibility and age of the patient. If simple 
vesication is desired, or what the French call a "flying blister," the 
cerate should remain on a shorter time than if a permanent one is 
required, or one destined to be kept open a long time ; in very sus- 
ceptible subjects, and particularly in children, great care is necessary 
that the irritation do not extend too far, as mortification of the integu- 
ments has happened in such patients. The safest plan in these cases 
is to keep the plaster on only until the skin is bright red, when a 
poultice must be applied, which will raise a vesicle in a few hours. 

The average time for the retention of a blister upon the skin in an 
adult may be stated to be four hours ; the skin of the scalp being 
much thicker than it is in other localities, will require a longer time 
for the plaster to vesicate — from twenty to twenty-four hours. 

The mode of dressing the blistered surface depends also upon the 
object had in view by the practitioner"; if it is not intended to keep 
up a discharge, the vesicle must be punctured with a lancet, or the 
points of the scissors, and the serum permitted to escape, when it may 
be dressed with a cerated cloth, an emollient poultice, or, what is 
more common in domestic practice, with a cabbage leaf; in two or 
three days the irritation will have subsided; and in four or six more the 
surface will be healed. Dr. Maclagan recommends a dressing of raw 
cotton after the serum is evacuated, which is to be renewed as often as 
it becomes soaked, care being taken not to pull off the cuticle in the 
operation. If a permanent blister is required, after the evacuation of 
the serum, the cuticle is to be removed, and a dressing of basilicon 
ointment, or some other stimulating substance is to be applied to the 
raw surface, which will prevent its healing, and increase its secretion. 

It has been suggested, when the patient is comatose, to tear the cuti- 
cle off suddenly, so that the sudden impression of the air upon the 
delicate nervous loops of the surface below may produce a salutary 
shock to the nervous system, tending to rouse the dormant energies. 

Another mode of using the cantharides is under the form of can- 
tharidal collodion, prepared by dissolving gun-cotton in an ethereal 
solution of cantharidin, the active principle of Spanish flies. It pos- 
sesses the advantages over the cerate of keeping a long time without 
change, and of being more prompt in its action ; it should be applied 
to the surface, prepared as in the former case, with a camel's hair 



CAUTERIZATION. 577 

brush, and covered with a piece of oiled silk. Cantharidin is also 
incorporated with wax, and spread in a very thin layer upon fine 
waxed cloth, silk or paper, constituting the blistering cloth, blistering 
paper, vesicating taffetas, etc. of the shops. 

When there is too much irritation of the blistered surface, and false 
membrane is formed upon it, great advantage will accrue from the use 
of emollient poultices ; while severe pain may be controlled by employ- 
ing the watery solution of opium, applied by a piece of soft old linen. 
Care should be taken that the suppurative action be not continued so 
long as to give rise to the formation of a thick and knotty cicatrix. 
If the discharge becomes profuse and fetid, poultices containing La- 
barraque's solution, finely-powdered charcoal, or creasote may be laid 
upon the part. 

When it is desired to stop the drain, an ointment consisting of equal 
parts of simple cerate and the cerate of the subacetate of lead will be 
found the most efficient application for this purpose. 

Blisters are sometimes produced for other purposes than counter- 
irritation, as when, from any cause, as the excessive irritability of the 
stomach, etc., medicines cannot be swallowed, their introduction into the 
system may be effected by simply placing them upon the denuded cutis, 
constituting what has been called the endermic method of medication. 

In this way morphia, quinine, and other remedies may be employed ; 
they should be finely levigated or powdered, so as to contain no gritti- 
ness to irritate the surface ; and, if too active, may be incorporated with 
some fatty or gelatinous matter. It is always better, when it can be 
accomplished, to simply make an aperture in the vesicle, and slip the 
medicine into it, so that the air may not come in contact with the cutis, 
which diminishes its absorbent power ; or to raise the cuticle, and, 
after sprinkling the powder upon the cutis, lay it down again. 

Should the remedies act energetically upon the system, their absorp- 
tion may be arrested by making compression upon the blistered sur- 
face. 



CHAPTER III. 

CAUTERIZATION. 

Cautebization is the process by which the vitality of the tissues 
is destroyed by heat or certain chemical agents, the former being called 
the actual cautery, and the latter potential cauteries. They act by de- 
composing the tissues, and thereby destroying the life of the part ; 
the new combination produced, generally dark-colored, and technically 
named the eschar, now becomes foreign matter, and is ultimately sepa- 
rated from the living tissues beneath by inflammatory action. 

1. Actual cauterization may be produced by several methods, which 
we shall consider seriatim. 

The red-hot iron was much employed by the ancients as a cautery, 



578 



CAUTEKIZATION". 



and highly lauded by Hippocrates. It continued to be used freely in 
numerous surgical diseases for centuries. In later times, Pouteau, 
Dupuytren, and the elder Larrey were its warm admirers, but at present 
surgeons have very much restricted the limits of its application. 

The effects of the actual cautery upon the body are : the production 
of moderate pain, and a black eschar at the point of its application, 
which is subsequently thrown off) leaving a suppurating surface 
beneath ; there is also a decided impression made upon the nervous 
system not observed to follow potential cauterization, whose influence 
is more local. The supervening inflammation produces a local deriva- 
tion and a general excitation, which latter may amount to fever if not 
checked by appropriate measures. It is important to remember that if the 
cauterization is only intended to destroy the tissues, the local inflam- 
mation ought to be restricted at once, if possible, to that degree neces- 
sary to throw off the eschar ; on the contrary, if a powerful derivative 
effect is desired, as in ulceration of the cartilages, for instance, Pott's 
disease, and coxalgia, the inflammation should be permitted to progress 
within safe limits; and hence it is, that repeated touchiug of the issue 
with the hot iron, when the inflammation decreases, is so much more 
beneficial and effective, in these cases, by renewing the counter-irrita- 
tive action, than any other sort of application for this purpose. 

The wound remaining after the separation of the eschar heals up 
rapidly, though a cicatrix of a size proportioned to the extent of the 
slough always remains. 

The ancients employed irons of various shapes and made of different 
metals, upon the supposition that the action of the latter was dissimi- 
lar ; but as heat is the efficient agent, it matters very little of what metal 
the cautery is made; though iron, or, better still, steel, is the material 
now used; steel changes color with the different degrees of temperature, 
so that the surgeon is enabled very well to decide by color alone how 
far the metal is heated. 

The cautery is provided with a wooden handle, to which irons of 
different shapes may be attached by means of a socket and thumb- 
screw ; these various forms are very well shown in the annexed wood- 
cut (Fig. 520). The conical cautery is convenient for cauterizing in 



Fig. 520. 




Different forms of the cautery. 



cavities, as the neck of the uterus, the walls of the vagina being pro- 
tected by a speculum previously introduced; the narrow pointed iron 



CAUTERIZATION. 579 

will enable the surgeon to reach the mouth of the bleeding vessel at 
the bottom of a wound ; and in obstinate hemorrhage from a stump 
which had resisted all other means, I emploj^ed this cautery with suc- 
cess. The nummular cautery having a broad surface is used to make 
issues, while the one with a hatchet-shaped extremity furnishes a form 
by which the cauterization may be restricted to narrow lines. 

Should the proper cautery iron not be at hand, an iron, rod, or spike 
of proper size, will answer well enough. 

The pain of the actual cautery will depend in a great measure upon 
the degree of heat of the iron, a white heat being much less painful 
than if the iron be heated to redness only. In forming a thick eschar, 
it is advisable to re-apply the iron brought to a white heat, for five or 
six seconds each time, rather than let it cool in contact with the 
tissues ; for then it sticks to the part, and, if forcibly withdrawn, may 
bring the slough with it, and thus, perhaps, renew a hemorrhage it 
was designed to check. 

The point at which the cautery is to be applied must be wiped dry, 
that the heat may not be absorbed in converting the secretions into 
steam ; and care should be taken also that the cauterization be not 
performed over the tracks of large bloodvessels and nerves. If it 
should be necessary to protect the adjacent parts, a cloth wrung out 
of cold water may be laid upon them ; or, in narrow passages and 
fistulous canals, a metallic tube, or one prepared with an ordinary 
visiting card, will secure their walls from contact with the iron. 

A common hammer dipped in boiling water and kept in contact 
with the skin ten or twelve seconds will produce an eschar, and has 
been recommended as a general excitant in suspended animation from 
prolonged immersion in water, and from poisoning by prussic acid 
and its compounds. Cloths wrung out of boiling water have been 
employed in the same manner; they will produce an eschar in from 
eight to ten minutes. 

Various combustible bodies have been used as cauterizing agents, 
such as phosphorus in small grains laid upon the skin and then set 
fire to. The pain produced is intense, and the contact of the phos- 
phoric acid formed with the wound causes an almost intolerable burn- 
ing sensation. Camphor and gunpowder have had their advocates,, 
but this method of cauterization is now properly abandoned. 

The actual cautery may be employed with advantage as a hasmos- 
tatic in sealing up the mouths of bleeding vessels in wounds or opera- 
tions in persons laboring under the hemorrhagic diathesis; to check 
hemorrhage following the extraction of teeth ; to arrest the progress 
of caries ; as a counter-irritant in chronic articular affections and; 
ulceration of the cartilages in angular curvature of the spine ; and in 
coxalgia. 

The galvanic cautery was first proposed by M. Heider, of Vienna,, 
in 1844, and afterwards tried in France by Sedillot, Amussat, and 
Xelaton, without, however, deriving the advantages claimed for it. 
by its advocates. In 1854, M. Middeldorpff, believing that the diffi- 
culty in the way of its practical use resulted from the want of a proper 
battery and suitable instruments, brought it prominently into notice 



580 



CAUTEKIZATION". 



again with improved appliances which rendered the application of the 
cautery convenient and effective ; and since that time it has been used 
by surgeons generally with more or less success in the treatment of 
those diseases in which the actual cautery is indicated. 

M. Middeldorpff employs a Groves' battery of four couples, to each 
pole of which a conductor is atttached two yards long, and composed of 
eight copper wires wrapped in silk (Fig. 521) ; the 
Fig. 521. distal extremities of the two conductors are con- 

nected with the tip of the ivory handle of the 
cautery by thumb-screws (A A) making a con- 
nection in this manner with two insulated wires, 
E, which run through the handle and terminate 
beyond it in two sockets furnished with two 
thumb-screws, F F, to receive the different forms 
of the cauteries; upon the side of the handle 
there is a little button (B) by pressing upon 
which the connection is instantly broken, and the 
electric current ceases to flow through the wires. 




Fig. 522. 



Fig. 523. 




Galvanic cauteries. 



The armatures of the ivory or ebony handle are variously formed ; 
the olive-shaped and nummular cauteries consist of a platinum wire 
wrapped spirally around grooved, thin, and hollow porcelain shells, 
which are rendered incandescent by the heat of the wire ; they are 
intended for the cauterization of some extent of surface, as in making 
issues, destroying the tissue about the neck of the uterus, &c. (Figs. 
522, 523.) 

The hatchet-shaped and conical cauteries are formed of narrow 
strips of platinum bent upon themselves in different ways. 

Galvanic setons are formed of platinum wires of different sizes, 
which are drawn through fistulous canals, or the tissues we propose 
to cauterize by straight or curved needles. Mr. Marshall, of London, 
who has paid a good deal of attention to this subject, devised the 
instrument seen in the annexed wood-cut (Fig. 524), for cauterizing the 
interior of serous or fungous granulations. 

The galvanic porte-ligature (Fig. 525, 5) is formed of a platinum 



CAUTERIZATION, 



581 



wire passing through two short metallic tubes borne upon a handle, in 
such a manner as to form a loop, which is placed around the base of 

Fig. 524. 




Marshall's galvanic seton. 

the part to be divided, and drawn tight by two handles attached to 

the extremities of the wire ; this instrument cuts the tissues perfectly. 

M. Eumkorff has substituted for Groves' battery employed by 

Middeldorpff that of Bunsen, seen in the adjoining illustration (Fig. 

Fig. 525. 




Bunsen's battery with, the cauteries attached. 

525). With this apparatus, composed of six elements, the desired 
amount of heat can be readily obtained. Figs. 1, 2, 3, 4, and 5 show 
the variously shaped cauteries described above. 

In applying these cauteries, they are to be placed in contact with 
the part cold : and then the galvanic current may be established and 
continued sufficiently long to obtain the object in view ; ordinarily, 
from five to fifteen minutes will suffice to procure moderate cauteri- 
zation. 

2. Potential cauterization is produced by various chemical agents, 
each possessing some peculiarity in its mode of action or degree of 
activity and manageability. That a caustic may act properly, a cer- 
tain amount of moisture is required ; if there is too much, the liquid 
will flow over the adjacent surface, or combining with the caustic will 



582 CAUTERIZATION. 

form a protecting layer between it and the parts beneath ; and hence 
it is necessary, in open wounds, sores, &c, where the secretion is 
abundant, to cleanse them of the pus, with pellets of lint before 
applying the caustic. 

The thickness of the eschar produced by a caustic will depend upon 
the nature of the substance used, and the length of time it is kept in 
contact with the skin. The milder articles, called catheretics, produce 
thin, light-colored eschars, which quickly separate from the parts be- 
low; the stronger ones form thick, black sloughs, which require a much 
longer period to become detached (sometimes a month or even more), 
depending upon the amount of inflammation produced. 

When the caustic has produced the effect desired, the part should 
be thoroughly cleansed of all excess of the material employed ; this 
may be accomplished with vinegar, if the caustic is alkaline, or with, 
a solution of carbonate of soda, if it should be acid. 

The greatest watchfulness will be required during the application 
of those caustics capable of being absorbed, and producing poisonous 
effects, such as the bichloride and the acid nitrate of mercury and 
arsenic, all of which have produced death in this manner. As a rule, 
these articles should not be spread over a large extent of surface, or ap- 
plied upon freshly-made or bleeding wounds. Berard has never seen 
any bad results follow the application of the bichloride of mercury 
after the hardened borders of the sore had been removed with the 
knife, and the caustic put on after the suppuration was established. 

The fused nitrate of silver is the caustic most frequently used by 
surgeons ; it produces, when applied to wounds, a thin white eschar, 
which separates in a day or two; upon the skin the eschar is brownish 
or of a deep violet color. 

The stick of nitrate of silver, brought to a point, is employed to 
cauterize ulcers of the cornea, in inflammatory affections of the con- 
junctiva and eyelids, in poisoned wounds, to arrest hemorrhage from 
leech-bites and small vessels, to suppress exuberant granulations, and 
to abort the pustules of variola, &c. 

Sulphate of copper is also a mild caustic or catheretic of great value 
in the treatment of inflammatory diseases of the conjunctiva, granular 
lids, &c. It is prepared for use by selecting a fine large crystal of the 
sulphate, and chipping one of its extremities to a smooth point, that 
the conjunctiva may not be injured by its roughness. 

Caustic potassa (potassa fusa) may be used alone, but it is more 
commonly mixed with lime, forming the Vienna plaster. Its action 
is very limited, so that it rarely extends to the subcutaneous cellular 
tissue, whatever the quantity of the article applied. 

The eschar is blackish, and separates in a few days. 

Caustic potassa is sometimes had recourse to for making issues, and 
opening abscesses, both superficial and deeply seated. It is applied in 
the following manner: A piece of adhesive plaster has a perforation 
made in it, and is then laid over the part to be cauterized ; upon this 
a fragment of the caustic, the size of a pea, is placed, and a second 
piece of adhesive plaster confines the whole. After this dressing is 
removed, a poultice is applied until the eschar comes away, or the 



CAUTERIZATION. 583 

latter may be incised with a knife. This plan has been pursued in 
opening abscesses of the liver, where the object is to produce sufficient 
inflammation to agglutinate the layers of the peritoneum together 
before issue is given to the pus, otherwise a fatal peritonitis would be 
likely to follow. 

It may also be used to cauterize poisoned wounds, but for this pur- 
pose it is much inferior to the liquid caustics, which more readily 
penetrate in every direction into pockets and crevices where some 
lurking portion of the poison might escape the solid caustic. 

The Vienna paste is prepared with fifty parts of caustic potassa to 
sixty parts of quicklime; the materials are to be thoroughly pul- 
verized before being mixed, and then made into a paste with a small 
quantity of alcohol ; the eschar formed is black, and comes away in 
eight or ten days. 

This caustic may be made in a more convenient form by melting 
the potassa in an iron pot, and then adding slowly the quicklime, stir- 
ring the while with an iron rod until the materials are thoroughly 
mixed, when they may be poured into cylindrical moulds of sheet-lead. 

In applying the Vienna paste, a layer two lines thick, and of the 
exact size of the eschar required, is laid upon the part; in five or six 
minutes the skin will be cauterized to the cellular tissue, which is 
known by the appearance of a gray line on the margins of the paste ; 
the caustic should then be removed with any dilute acid. If deeper 
cauterization be required, fifteen or twenty minutes will be necessary. 

Arsenious acid forms the active ingredient of several cauterizing 
powders and pastes which have enjoyed much reputation for their 
efficacy in destroying cancerous and other morbid growths ; among 
these may be mentioned, as the best known, the powders of Eousselot 
and of Dupuytren, and the paste of Manec. 

Bousselot's caustic may be prepared by mixing sixteen parts each of 
the red sulphuret of mercury and dragon's blood, with eight parts of 
white oxide of arsenic; before being applied, the powder must be 
made into a paste with a little gum-water. 

Maheds paste is composed of fifteen grains of arsenious acid, seventy- 
five of the red sulphuret of mercury, and thirty-five of burnt sponge. 

A layer of either of these preparations, from one to two lines thick, 
may be spread upon the sore, and covered with lint, over which a 
bandage is placed. The eschar is made in a few days, and is thrown 
off between the tenth and twentieth, bringing with it the caustic paste ; 
the surface beneath, after one application, will generally present a 
healthy appearance, though it may be necessary to apply it again and 
again before all the diseased tissues are destroyed. 

Swelling of the face, and oedema of the eyelids follow its applica- 
tion to the face, but these subside in three or four days without any 
further accident. 

These caustics are most frequently employed in the treatment of 
lupus and some cancroid diseases. 

The paste of the chloride of zinc (Canquoin's caustic) is composed 
of chloride of zinc and flour, which, absorbing moisture from the 



584 



CAUTERIZATION-. 



atmosphere, becomes converted into an elastic mass, that may be 
readily applied to the surface. 

Canquoin employed pastes of three different strengths, the first con-, 
taining one part of the chloride of zinc to two of flour, the second, one 
part to three ; and the third, one part to four. 

The caustic does not spread, and acts cleanly to a depth proportional 
to the thickness of the paste employed. 

The acid nitrate of mercury is also an active escharotic, but requires 
care in its management ; no large absorbing surface should be caute- 
rized with this fluid, as it may produce excessive ptyalism, violent 
colics, diarrhoea, etc., and its use has in a few cases resulted in death. 
The part to which it is applied must be well cleansed, and freed from 
moisture ; the caustic may then be applied with a brush, or a piece of 
lint mounted upon a wooden stem. It has been principally used to 
cauterize chancres and ulcerations about the neck of the uterus. 

Cauterizing pastes may also be prepared with the concentrated min- 
eral acids, with tow, sawdust, asbestos, or saffron ; but they are not 
near so manageable as Manec's or Canquoin's caustics. 

Malgaigne prefers the caustic recommended by M. Kecamier to the 
acid nitrate of mercury. It consists of a solution of the chloride of 
gold in nitro-chlorohydric acid, and cauterizes deeply, while the eschar 
formed by it separates in three or four days. It gives but little pain, 
and its action is purely local. 

Dr. Simpson thinks highly of a paste made of the sulphate of zinc, 
with glycerine or lard in the proportion of an ounce of the sulphate to 
a drachm of glycerine, or two drachms of lard. 

M. Maisonneuve reported a plan of cauterization to the Academy 
of Medicine, in Paris, in 1848, differing from that usually pursued, in 
that the caustic is made to act from the interior of the parts to be 
destroyed to their surface. 

For this purpose he selected the caustic of Canquoin already men- 
tioned, from the fact that it can be easily moulded into any desired 
shape, possesses no toxic effects, and is a powerful hemostatic. 

The paste is rolled into a circular cake, and cut into wedge-shaped 



Fig. 526. 



Fig. 527. 



Fig. 528. 




Mode of cauterizing 

Maisonneuve's plan of circular cau- Maisonneuve's plan of parallel small tumors with a 
terization by wedge-shaped pieces of cauterization by lancet-shaped pie- spindle-shaped piece of 
caustic. ces of caustic. caustic. 



moxa. 585 

pieces of an appropriate size by lines extending from the centre to its 
circumference ; when dry the pieces are ready for use, and are then 
thrust into the midst of the morbid growth through little incisions 
made at equal distances around its base, as seen in Fig. 526. 

In other cases, where the tumor cannot be circumscribed in this man- 
ner, the pieces of caustic may be made lancet-shaped, and lodged in 
the tumor in a parallel direction, as seen in Fig. 527. 

This process succeeds well in those regions where the morbid tissue 
lies deeply among other parts; as in the axilla, neck, groin, vagina, 
and rectum. Small tumors may be attacked by a single spindle- 
shaped piece of caustic thrust to its centre, through an incision made 
with the bistoury, as shown in Fig. 528. 

Mr. Paget, of London, has employed in certain cases lancet-shaped 
pieces of wood dipped in fused chloride of zinc. 



CHAPTER IV. 

MOXA. 

The moxa is a combustible substance, which is burnt slowly upon 
the skin, usually producing an eschar. It has been used by the orien- 
tals in medicine for centuries ; they prepared it from the dried leaves 
of the Artemisia moxa, a species of the mugwort, which were beaten 
and formed into the shape of small cones. Many other articles have 
been used for the same purpose as the pith of the greater 
sunflower (Helianthus aureus), punk, cotton, and paper 1 ^T ' 
rendered more combustible by soaking it in a solution of 
the nitrate or chlorate of potassa. A convenient moxa 
may be made of raw cotton, moderately compressed, and 
wrapped with silk or cotton-cloth, so as to form a cylinder 
an inch long by one to two inches in diameter ; this may 
be stuck to the part, where the counter-irritation is to be 
established, with a little gum, or held in contact with it 
by a little instrument designed for the purpose, consisting 
of a handle supporting a ring, in which the moxa is 
secured by two pins passing through it, and the minute 
holes perforating the circumference of the ring; the 
moxa is then set on fire and kept in a uniform state of 
combustion by a stream of air driven from a small blow- 

• t n ,i .i i Porte-moxa. 

pipe, or, more simply, from the mouth alone. 

To protect the surrounding parts, a wet cloth should be laid over 
them ; or, what is better, a card with a hole cut in it. 

The combustion should be allowed to go on slowly in order to pro- 
duce the greatest amount of counter-irritant effect, and an eschar of 
sufficient thickness, if the latter is desired. Where a more moderate 



586 issue. 

action is required, a piece of thick cloth, wetted with water, may be 
interposed between the skin and the moxa. 

The skin is at first reddened, and the patient experiences a plea- 
sant sensation of warmth, which, as the fire approaches the surface, is 
converted into a decided pain ; the skin crackles as its moisture is 
dissipated, and is finally converted into a fissured black eschar, while 
the parts just around it are reddened and vesicated. 

The eschar separates in from ten to fifteen days, leaving a sore 
which readily heals. 

The first dressing should be a simple bit of adhesive plaster, laid 
over the cicatrized surface ; and when pus begins to ooze from be- 
neath its edges it may be replaced with the simple dressing. If the 
resulting inflammation is too severe, it should be controlled with 
water-dressings. 

The moxa should not, as a rule, be employed over the course of 
large vessels or nerves, nor upon bony prominences. 

Moxibustion is employed to produce revulsion in caries and other 
chronic diseases of the bones, in obstinate neuralgias, and chronic 
inflammations. 



CHAPTER V. 

ISSUE. 

An issue is a counter-irritative, suppurative discharge established 
in the subcutaneous cellular tissue. It is not so prompt in its action 
as the rubefacients and vesicants, but is more permanent in its effects, 
and more exhaustive. 

The issue may be made at almost any point, taking care always to 
avoid osseous and muscular eminences, and the courses of the large 
bloodvessels and nerves. It is usual to select some part where the 
issue would be exempt from any interference in consequence of mus- 
cular movements ; from the rubbing of the clothes against it, &c. ; and 
at the same time permit the convenient application of the necessary 
dressings. 

In local diseases it will generally be desirable to place the issue 
over the suffering organ, or as near to it as possible. 

The point of selection, in affections of the head, is the back of the 
neck. Yelpeau prefers the triangular space bounded above by the 
occiput, at the sides by the splenic muscles, and having its apex at 
the spinous process of the axis ; his reason is, that in this spot there 
is a thick bed of cellular tissue and muscle in direct vascular connec- 
tion with the internal parts, and in proximity with large and import- 
ant nerves. Others recommend that it be placed lower down, so 
that it may be concealed by the dress. In the arm, the space be- 



issue. 587 

tween the deltoid and biceps, near the insertion of the former muscle, 
will be found most eligible. 

An issue for the lower extremity is generally established at the 
depression upon the inner side of the thigh, about two or three inches 
above the inner condyle, just over the vastus internus; though in 
this situation the dressings are not so easily maintained, both from 
the conicity of the thigh and the disturbing influences of locomotion. 
The points above mentioned are the most desirable for the establish- 
ment of a permanent issue. For temporary counter-irritation, while 
the patient is confined to bed, any part above the suffering organ, 
with the exception we have made above, may be chosen — in dis- 
eases of the lungs, the depressions beneath the clavicles ; in those of 
the abdomen, over the liver, duodenum and iliac fossa, according to 
the situation of the organ. In affections of the spine, any portion of 
the vertebral grooves will answer for the seat of the issue — alongside 
of any particular vertebra that may be diseased. 

Issues are made in several ways ; the first and most valuable is 
with the actual cautery. The iron should be heated to whiteness, and 
applied quickly to the part, and as quickly removed before it has 
time to cool. The eschar formed is black, and generally separates in 
five or six days. AVater-dressings should be employed until this 
occurs, and the surface kept discharging by the application of some 
stimulating ointment or foreign body; or, what is better, by passing 
the heated iron slightly over the surface as occasion requires. 

When the iron is white hot, there is no great pain produced, for the 
obvious reason that the nerves of the part are instantly deprived of 
their vitality. 

The potential cautery is also employed for the same purpose. In 
using the potassa fusa it should be remembered that the eschar will 
be twice as large as the fragment of caustic, from its great tendency 
to spread; its mode of application has already been described at page 
582. At the end of five or six hours, or when the pain ceases, the 
dressings should be removed and the part examined ; in the centre of 
a circle of inflammation will be found the black and dead integument, 
forming an eschar, which it is now the object to get rid of; a poultice 
may be applied repeatedly, which will bring away more or less of the 
slough at every dressing ; in this manner in from ten to twenty days 
it will be completely removed. 

Irritating ointment or peas are then applied to keep the sore 
discharging. 

Some have recommended the eschar to be cut across, a pea put in 
the incision and confined with a bandage: as the issue progresses the 
eschar softens, turns gray, and finally drops off, leaving a clean granu- 
lating surface beneath, which must be kept discharging by peas, 
glass beads, or other irritants, to which a thread may be attached to 
facilitate their removal when it becomes necessary. 

The Vienna paste is preferable to the potassa fusa in making an 
issue, inasmuch as it does not spread upon the surrounding tissues, in 
consequence of the lime it contains restraining the fluidity of the 
caustic potassa, while at the same time it renders this more active by 



588 issue. 

seizing any carbonic acid that may be present in it. The eschar 
formed is of a pale drab color, and separates in seven or eight days. 

The caustic is applied in the same manner as the potassa fusa, and 
permitted to remain in contact with the skin ten or fifteen minutes, 
when it is removed by washing the part in some dilute acid ; a poultice 
is then applied. 

Blisters have been used to make an issue, but the process is ineffi- 
cient and painful ; the blister simply destroys the cuticle, and the peas 
have to be bound on so that they may penetrate the cutis by ulcera- 
tion ; in this manner the discharge of pus will, of course, be delayed, 
and its quantity be small until this result is obtained. 

Dr. Golding Bird has recommended the following plan to procure 
a clean, healthy granulating surface with a free discharge of pus : 
Apply two small blisters within a few inches of each other, and after 
the vesicles are formed discharge the serum ; over the blister intended 
for the issue place a zinc plate, and upon the other one a silver plate, 
then connect the two together with a copper wire. In forty-eight 
hours a decided eschar will be formed under the zinc plate, and sup- 
puration will be established in four or five days, when the apparatus 
must be removed and a poultice applied; the skin beneath the silver 
plate will be found entirely healed. 

The explanation of the action of the apparatus is that the galvanic 
current decomposes the chloride of sodium of the serum, evolving 
chlorine at the positive, or zinc pole, which, seizing hold of that 
metal, forms the chloride of zinc, the well-known escharotic. 

The quickest and least painful manner of forming an issue is with 
the knife ; but it is inferior to the other plans in its immediate revul- 
sive action, as the irritation of a clean cut bears no comparison with 
the slow destructive effects of the caustics or the violent impression 
of the actual cautery. 

This method is better adapted to the scalp than to any other region, 
and has been pursued in certain affections of the meningeal membranes. 
The incision should be from a half to an inch in length, proportional 
to the size of the issue ; and rather than make a long incision, a 
crucial one should be preferred through the skin and cellular tissue ; 
in this incision place some foreign body, as a garden pea, a small 
piece of gentian or orrisroot, a grain of corn, a small pebble, or a 
glass bead, which will produce the suppurative action in three or four 
days. Should this be delayed, the foreign body may be spread with 
some stimulating ointment, mezereon, for instance. After the suppura- 
tion is once established, a simple dressing once a day will generally 
suffice to insure cleanliness. If the granulations become fungous, 
they should be repressed with the nitrate of silver ; severe inflamma- 
tion must be met with water-dressings, poultices, &c. 

An issue may be readily healed by withdrawing the irritating body 
from it, and substituting a simple dressing. 



SETON. 



589 



CHAPTER VI. 



SETOX. 



The seton, from seta, a "bristle," is made by passing a strip of some 
material beneath a narrow tongue of the skin and cellular tissue, to 
establish a secretion of pus. The name is applied both to the wound 
made and to the material put into it. 

Occasionally the seton is used with other views than as an exutory, 
as when a thread or cord is introduced into the tunica vaginalis, or 
between the ends of a broken bone. Here the object is, in the first 
case, to excite the adhesive inflammation, and in the second, to cause 
an effusion of reparative material. It has also been placed in cavities, 
to facilitate the escape of a foreign body, as in old gunshot wounds 
where the projectile has not yet escaped; but for this purpose it is 
now obsolete. 

Again, where there is a constriction of some duct of the secreting 
glands, the seton is had recourse to, to dilate it ; as in fistula lachry- 
malis, and in Stenon's duct in salivary fistula. 

As an exutory, setons are now generally applied to the neck about 
the height of the fourth or fifth cervical vertebra, and to the inner 
sides of the extremities; they have also been used upon the chest and 
abdomen, and, in obstinate disease of the uterus and bladder, over the 
pubis. 

In very irritable subjects this mode of counter-irritation is extremely 
painful, and will often have to be abandoned for some other method, 
more especially if inflammation and suppuration of the cellular tissue 
to a considerable extent follow, as they sometimes do ; in tljese cases 
the little tongue of skin usually sloughs, leaving an open wound. 

The operation is simple, and may be performed with the seton - 
needle, or with an eye-probe and bistoury. The seton-needle, as seen 

Fig. 530. 




Seton-needle armed. 



in Fig. 530, is a flat, lance-shaped instrument, four or five inches long, 
by six lines broad, with a large eye at its heel, to carry the thread or 



590 seton. 

tape. It is used by raising a fold of the integuments between the 
fingers, and thrusting the needle through its base, when the point of 
the needle is seized and the threads drawn into their place. 

The second method, with the bistoury and probe (Fig. 531), is better, 
as these instruments are always at hand, and, in drawing the seton into 
the wound, the fingers will not slip from the probe, as they do from the 
needle covered with blood and resisted by the elasticity of the tissues. 

A fold of skin is raised with the thumb and three fingers of the left 
hand ; the bistoury, held in the right, with the edge downwards, is 
passed through its base, giving the point of the knife a little inclina- 
tion downwards, so that one of the parallel incisions may be a little 
longer than the other, in order to facilitate the escape of pus ; the 
probe, armed with the seton, is now passed beneath the skin upon the 

Fig. 53L 




Vtode of introducing a seton. 



back of the blade of the bistoury, when the latter is to be withdrawn, 
while the seton is pulled into the position it is destined to occupy. 
A little blood escapes from the wound at first ; but soon ceases, and in 
three or four days suppuration is established. 

The material of which a seton is made is a skein of cotton, a narrow 
piece of cotton cloth, or, what is better yet, a thin slip of India-rubber. 
This is to be drawn beneath the skin a little way at each dressing ; 
and when it is exhausted, before the last remnant is removed, a new 
slip should be loosely tacked to its end, to be palled into the wound 
in its turn. If a strip of India-rubber is employed, it does not need 
renewing, but may be simply sponged clean. 

The long end of the seton should be on the side of the shortest 
incision, so that it may not be soiled by the pus. 

As to the dressing, a poultice may be applied until the suppurative 
action is established, and then a simple dressing, or a perforated com- 
press smeared with cerate, may be laid on the wound and covered 
with a little charpie, the whole being secured by the circular bandage 
of the neck. This dressing need not be disturbed for three or four 
days, and after the wound begins to. suppurate it should be dressed 
every day ; if the discharge is very abundant, twice daily, the soiled 
part of the seton being removed with the scissors. 

Should the suppurative action be tardy, a little ointment of basilicon 
or cantharides may be put on the seton. 

This mode of making counter-irritation is far inferior to that by 
the issue, being less cleanly and efficient. 



ACUPUNCTURE AND ELECTRO-PUNCTURE 



591 



CHAPTER VII 



ACUPUNCTURE AND ELECTRO-PUNCTURE. 



Figs. 532, 533, 534. 

0\ jRt 



1. Acupuncture consists in the introduction of metallic needles 
into the tissues of the body. It is an extremely simple operation, the 
needles passing between the fibres without dividing them or shedding 
blood. 

The method was introduced into Europe by the Dutch surgeon, 
Then-Eyne, who had resided on the island of Desima, at Nangasaki, in 
Japan, and there learned the plan. It is of the highest antiquity, accord- 
ing to the Oriental physicians, and I have seen it generally practised by 
the native surgeons both in China and Japan. The needles used may 
be made of gold, silver, platinum, or steel ; they should be slender, 
sharp, and well polished, in order to penetrate the tissues without dif- 
ficulty. A small steel handle, with a ring at one 
end and a socket at the other, to receive the needles, 
completes the instrument either for acupuncture or 
electro-puncture. In employing the needle, it may 
be seized in the hand, and plunged, at one stab, to 
the required depth into the painful part, or driven 
in by a quick, smart blow with a ruler. I prefer, 
however, to rotate the needle between the thumb 
and index finger, making gentle pressure all the 
time until the point of the needle is put in the 
position required. 

The operation has been practised upon almost 
every part of the body, but it will be prudent to 
avoid thrusting the needle into the splanchnic cavi- 
ties and large bloodvessels; with these exceptions, 
the instrument may be shoved boldly into any part 
of the body to a depth of one, two, or three inches, 
as circumstances may direct. 

The number of needles that will be required in Acupuncture needles. 
any case will vary from three or four to twelve ; I 
introduced twenty in an obstinate case of sciatica with advantage. They 
may be permitted to remain in for a few minutes — or, as is generallv 
done, two or three hours; there will be no objection to extending the 
time to two or three days. 

To remove the needle, press the skin at the point of puncture with 
the tips of the fore and middle fingers of the left hand, and draw the 
handle towards you with the right. 

Usually a little blush of redness will surround the puncture, and 
perhaps a slight numbness will be present ; though in certain cases 
patients have been known to suffer extreme pain during the opera- 
tion and after the needle has been removed. In a few instances, 



692 PUNCTURING. 

where the needles have not been properly tempered, they have been 
broken by the strong muscular contractions excited by them. 

Acupuncture has been recommended in the treatment of neuralgia, 
sciatica, angina pectoris, paralysis, chronic rheumatism, and chronic 
gout. Eecently it has been used in aneurism, anasarca, hydrocele, and 
varicocele. I know of two cases of hydrocele radically cured by the 
persevering use of the needles. Carrero has employed it also in cases 
of asphyxia from drowning, and other causes, by thrusting the needles 
into the heart and diaphragm. 

2. Electro-puncture is performed after the needles have been intro- 
duced as above directed, by attaching to the rings of the steel handles 
the poles of a galvanic battery, and sending a current of electricity 
through the tissues intervening between the needles. If it is desira- 
ble to communicate a shock, the Leyden jar, charged with electricity, 
may be used. During the passage of the current the patient feels 
more or less pain, and an unpleasant contraction of the muscles, which 
cease with the interruption of the current. Over the electrized part 
little blisters and boils sometimes form. 

Electro-puncture has been used in the same kind of cases as acu- 
puncture. 



CHAPTER VIII. 

PUNCTURING. 

Puncturing is the operation of thrusting an instrument either 
sharp at its point only, or also cutting upon its edges, into the tissues 
or cavities, natural or morbid, of the body. 

The simplest form of a puncture consists in making little wounds 
into the skin or mucous membrane with a needle, to evacuate infil- 
trated fluids beneath them. This operation may be performed upon 
any part of the body, as the scrotum and legs in dropsical effusions ; 
the instrument required is a needle, or a very slender-pointed bis- 
toury, which should be thrust perpendicularly through the skin, and 
withdrawn in the same direction without enlarging the wound ; the fibres 
are simply separated, and no loss of substance or cicatrix follows. 

Great care should be taken in puncturing the skin in oedematous 
leg, as it becomes very thin by the pressure of the effused fluids, and 
impaired in its nutritive activity. Instrumental interference has some- 
times caused an erysipelatous inflammation, resulting in gangrene. 

Scarification differs from puncturing in that the point of the lancet 
or bistoury penetrates the tissues more deeply, and divides the fibres 
of the parts; in fact it consists in making little incisions. 

The operation can be performed either with the lancet, scalpel, or 
scarificator. 

It is employed in phlegmonous erysipelas to favor the escape of 
pus, in chemosis, in sanguineous congestions of the tongue and tonsils, 
and in oedema of the glottis. 



PUNCTURING. 



593 



For the purpose of evacuating the fluid accumulated in morbid 
or the natural cavities, the lancet, bistoury, or trocar is used. 
In opening abscesses, the 



Fig. 535. 




Manner of holding the bistoury in opening abscesses. 



to be done otherwise. 

seen in Fisr. 536 best suited to 



Fie:. 536. 



bistoury is, perhaps, the 
best instrument; it should 
be held in the manner 
shown in Fig. 535, when 
the hand is steadied with 
the little finger, while the 
instrument is pushed for- 
ward by the movements of 
the thumb, index, and mid- 
dle fingers. The puncture 
should be made generally 
at the thinnest part of the 
swelling, and in a line pa- 
rallel with its long axis, 
should no special reason require it 

Mr. Fergusson deems the attitude 
crises where pus is deep-seated, and 
when, probably, the surgeon has 
misgivings as to its presence at all. 

The forefinger of the left hand is 
placed over the abscess with gentle 
pressure : the back of the knife rests 
against the side of the finder while 
the tissues are divided to the desired 
extent. 

Should "Syme's abscess lancet" 
be employed, the best position for 
holding it to prevent its point sud- 
denly plunging into the abscess is 
that seen in Fig. 537, in which the 
hand is steadied and supported with 
the little finger. 

In puncturing the chest and abdo- 
men, an instrument called the trocar 
(Fig. 538) is used ; it is a cylindrical 
metallic stem fitted to a large bulb- 
ous handle, and terminating in a 
sharp point with three cutting edges; 
fitting over this stem there is a mova- 
ble tube, restinsr asrainst the handle 

o o 

by its funnel-shaped expansion, and 

reaching within a quarter of an inch of the point of the stem, w r hich 
it should clasp closely, that there may be no jutting shoulder to im- 
pede its progress through the tissues. 

In using this instrument it is held in the palm of the right hand 
by the last three fingers and the thumb resting against the junction 
of the stem with the handle, while the index finger is extended along 
38 




Manner of holding the bistoury in opening 
deep-seated abscesses. 



594 



VACCINATION, 



the canula to graduate the depth to which the point is to be plunged ; 
it is then to be thrust into the cavity quickly and the trocar removed 

Fig. 537. 







Mode of holding "Syme's abscess lancet." 

leaving the canula in the wound. When the cavity is large, as the 
fluid escapes its walls collapse, and the canula will be displaced if the 
operator does not support it with his fingers; the position of the 
point of the canula may also be changed occasionally to facilitate the 
escape of the fluid. 

Fig. 538. 




The trocar. 



Valvular puncture differs from the foregoing only in the skin being 
shifted a little to one side before the puncture is made, so that after 
the fluid escapes, and the instrument is withdrawn, the internal and 
external orifices do not correspond when the parts again resume their 
normal relation. 



CHAPTER IX. 

VACCINATION. 

Vaccination is a process which consists in inserting the vaccine 
virus beneath the cuticle, so that it may come in contact with the 
absorbents. 

This little operation can be performed at any point of the sur- 
face, though the place of election should always be the arm, and in 
infants the arm farthest from the nurse in the position they are usually 
carried. 



VACCINATION". 595 

The virus is effective in persons of all ages, though it is always 
prudent to perform the operation, when there is any choice left, at 
the age of three or four months. 

Some persons bring the virus in contact with the absorbents by 
simply scratching the cuticle from the cutis with the point of a lancet ; 
some make three or four little incisions into the skin at right angles 
to each other ; others again form little pockets by pushing the point 
of the lancet obliquely between the epidermis and true skin a distance 
of the one-sixteenth of an inch. 

Some physicians prefer an instrument specially constructed for 
vaccination; it resembles the ordinary lancet somewhat, though 
smaller, and has a slight groove upon one side of the point of the 
blade to receive the virus which is obtained from the vaccine vesicle 
between the sixth and tenth day of its appearance, when it should be 
limpid ; or, as is more commonly done, a small piece of the scab is 
powdered and mixed with water. 

When the operation is terminated, the arm is left exposed to the 
air for some time, until the blood dries upon the surface to protect 
the vaccine matter in the punctures ; a loose circular bandage of soft 
linen may then be applied to prevent the chafing of the arm. 

About the end of the third day, after a successful vaccination, the 
skin a little way around the puncture becomes hard and a little red ; 
on the fifth or sixth day the areola increases in size, and an effusion 
takes place beneath the cuticle, forming a vesicle of a roundish form 
and of a silvery or pearly color; the vesicle is depressed at its centre, 
or umbilicated ; and continues to increase in size to the eighth day, 
when the fluid is limpid and transparent and contained in a number 
of little cells; on the ninth day the vesicle becomes darker at its 
centre, which has ceased to present the umbilicated appearance, and 
becomes flattened ; the areola surrounding it has gradually increased 
in size, become of a vivid red color, and occasionally presenting a 
number of transparent vesicles. On the tenth day, the swelling and 
heat in the part have considerably increased, restraining the free motion 
of the arm ; the glands in the axilla are swollen and tender. At this 
time the patient experiences some little febrile excitement, and occa- 
sionally there is an erythematous blush over other parts of the body. 
On the eleventh day, the fluid in the vesicle becomes purulent and the 
areola commences to fade, and the general symptoms, if they have been 
present, diminish in intensity ; or disappear if they have been slight. 
The desiccation of the vesicle proceeds from the centre to the circum- 
ference until it is converted into a brownish circular scab which deepens 
in color to a brownish black in a few days, and diminishes in size; the 
inflamed areola has decreased apace with the desiccation of the vesicle 
until the twentieth day, when the crust falls off, leaving a depressed 
cicatrix of a circular contour with little pits upon its surface. As it 
is not always convenient or even possible to transfer the vaccine virus 
from one arm to another (though it is evidently the most efficient way), 
it is important that proper care should be taken to preserve the ''scabs;" 
and in collecting these, that the subjects from whom they are obtained 



596 incisions. 

shall present palpable evidence of exemption from any scrofulous or 
venereal taint, chronic skin diseases, and general debility. 

The crusts may be preserved for a long time by wrapping them 
in alternating layers of yellow or white wax and tin-foil. I vacci- 
nated a patient successfully with matter thus protected nearly two 
years old. 

To collect the lymph from a vesicle, the best plan, according to 
MM. Bretonneau and Fiard, is to use capillary glass tubes, which, after 
the fluid has been drawn into them, are to be hermetically sealed by 
holding their extremities for a moment in the flame of a spirit lamp. 

Another plan consists in receiving the virus from the vesicle upon 
a glass plate, to which it will adhere; another glass plate is now laid 
over the first, and their edges joined together with wax or by pasting 
paper around them. 

Jenner soaked up the fluid with threads ; the vaccine virus is in 
this method always exposed to the air, and is soon destroyed. 

The lymph may also be received upon ivory, pearl, or horn slips 
shaped like the blade of a lancet, and sharp enough to enable the 
surgeon to thrust their points beneath the skin. 

To preserve the matter for a few hours the point of a lancet will 
answer ; but after this time the metal quickly oxidizes and destroys 
the virus. 

Should an unusual amount of inflammatory action take place around 
the vesicle, a soft linen rag wrung out of hot water may be laid on 
the parts ; or a solution of the subacetate of lead, taking care not to 
rub the crust off the arm. 

Vaccinia having run the ordinary course described above, the patient 
is generally preserved the balance of his life from smallpox — I say, 
generally, for instances are recorded where smallpox has attacked 
patients after successful vaccination. 



CHAPTER X. 

INCISIONS. 

Incisions are solutions of continuity of the soft tissues made with 
cutting instruments. They are so constantly employed in various 
manners by the surgeon in the routine of practice as to constitute a 
large portion of operative surgery ; hardly a surgical procedure can 
be accomplished without involving to a greater or less extent the 
division of the tissues. They often constitute in themselves little 
operations, as the opening of abscesses, scarifications, punctures, &c. 
The larger operations, as amputations, ablations of tumors, &c, are 
nothing more than simple incisions variously modified to suit the 
exigencies of particular cases. 



INCISIONS. 



597 



Incisions are practised with a variety of instruments, but those 
principally used are scalpels, bistouries, and the scissors. 

Certain rules have been laid down by some distinguished surgeons 
to govern the manner of holding the knife ; and although most per- 
sons will hold the instrument as best suits their convenience and the 
attainment of the object they have in view, yet it will be well for the 
young surgeon to learn early those positions which have been found 
by experience to be the most convenient and graceful in making the 
various incisions required in operating. 

Fig. 539. 




Scalpel held as a pen. 

In Fig. 539 the scalpel is held as a pen, with its edge downwards ; 
the index-finger and thumb supporting it at the junction of the blade 
with the handle; the middle finger is a little in advance of the index, 
•upon the side of the blade ; the ring and little fingers are free, and, 
resting upon the skin, serve to support the hand. This position is 
convenient in making punctures and short incisions; in those of greater 
length, the hand may be drawn along the surface, still steadied by the 
ring and little fingers, or the latter may be raised from the skin so as 
to give it the greatest latitude of motion. The pressure upon the 
knife must be proportioned to the depth it is necessary to carry the 
incision, the resistance of the tissues, and the proximity of important 
parts. 

This position may sometimes be advantageously modified by turn- 
ing the edge of the blade upwards, as in cutting upon a director from 
within outwards, opening abscesses, &c; or, again, by drawing the 
blade beneath the palm of the hand, with its edge either turned up or 
down, according as the operator desires to cut towards or from himself. 

In Fig. 540 is shown a method in which the thumb is placed upon 
the articulation of the blade with the handle, and the fingers upon the 

Fief. 540. 




Scalpel held as a violin-bow. 



opposite side; it permits the freest movements of the knife, and is 
adapted to rapid and extensive incisions. The cutting edges can be 
directed, according to circumstances, upwards and downwards, or to 
either side. 



598 



INCISIONS, 



A very elegant position, in which the hand has the most perfect 
control over the knife, is seen in Fig. 541. The handle is held in the 

palm of the hand by the ring 
Fi S- 541 - and little fingers, the thumb 

and middle finger being placed 
near the articulation, while the 
index is extended along the 
back of the blade. 

There are several modes, 
also, of making incisions either 
from within outwards, or the 
reverse; upon a director, or 
without one; and in certain 
cases, where the part to be 
divided is some distance below 
the surface, and cannot be seen, 
the point of the finger may be 
used as a director upon which 
the point of the knife may be 
guided, and at the same time 
prevented from damaging the 
surrounding organs; this method is sometimes employed in dividing 
constricting bridles, as in relieving strangulated hernia. (Fig. 542.) 

Fig. 542. 




Bistoury held as a carving-knife. 




Manner of using bistoury with the finger as a director. 

The direction of incisions will vary in each case, according to the 
objects the surgeon desires to obtain, and it may, therefore, run from 
right to left, from left to right, towards the operator, or in the contrary 
direction. As a general rule, it will be desirable, if possible, to make 
incisions in the same direction as the muscular fibres, large bloodves- 
sels, and nerves; so that in the extremities they would be longitudinal, 
oblique over the pectoral and abdominal muscles, and parallel with 
the natural folds in the palms of the hands, groins, and soles of the 
feet, and with the branches of the facial nerve upon the face. 

In making an incision with the knife, in order to avoid the partial 
division of the skin at the extremities of the incision, and thereby 
forming what are technically called "tails," the instrument should be 
introduced perpendicular to the surface, then brought down to a less 
angle with it, and drawn along to the desired extent; when the handle 
is to be again elevated, and the blade withdrawn perpendicularly. 



INCISIONS, 



599 



That the incision may be neat, it will be necessary to stretch, or at 
least to support, the integuments while the scalpel is cutting through 
the tissues. This may be done with the outer border of the left hand 
and thumb placed in a parallel position upon each side of the incision, 
and exercising gentle traction in opposite directions ; or the part may be 
grasped in the left hand at a point opposite the incision, and with the 
fingers and thumb moderately tighten the skin ; this plan is adapted 
to those portions of the body, such as the testicles, and the smaller sec- 
tions of the limbs, that the sursjeon can encircle with his hand. The 
same purpose may be also accomplished by making the incision be- 
tween the left index and middle fingers laid parallel upon the surface. 

Simple incisions are those made with one stroke of the scalpel, and 
are those most frequently used; they may either be straight or curved, 
as seen in Figs. 543 and 544; both of 

them are made in the manner already de- Fi g- 543. Fig. 544. 

scribed; in the curved incision the con- 
vexity may be directed towards any point 
that may be deemed best to secure the 
object in view. 

Compound incisions are those formed by the meeting of two or more 
simple ones, and receive the names of the letters which they resemble. 
Those most frequently used are seen in Figs. 545, 546, 547, and 548. 



Straight incision. Curved incision. 



Fig. 545. 



Fig. 546. 



Fig. 547. 



Fig. 548. 



V-shaped incision. H-shaped incision. L-shaped incision. 



T-shaped incision. 



In making these incisions, the second simple incision should always 
terminate in the first, and not begin from it ; and, that the blood may 
not conceal the place where the second incision is to be located, the 
first and lower one ought to be made first. Their object is to expose 
the parts beneath the integuments more fully than could be effected 
with simple incisions. They form flaps of greater or less size, accord- 
ing to their extent, which are dissected from the deeper tissues and 
raised up ; thus affording an opportunity to the surgeon to gain free 
access to and remove morbid structures, 
however deeply placed they may be. 

A large extent of surface of deeply- 
seated parts may also be exposed by 
the crucial incision seen in Fig. 549, 
which consists of two simple incisions 
crossing each other at right angles. 

In many cases of large tumors it 
becomes necessary to remove a portion of the integuments entirely, 
so that the resulting flaps may just cover the parts beneath ; this is 
accomplished by an elliptical incision such as is seen in Fig. 550 ; it 
is formed by joining two curved incisions at their extremities. The 
semilunar incision may be also used for the same purpose as the 



Fig. 549. 



Crucial incision. Elliptical and semilunar 




600 BLOODLETTING. 

elliptical, but it is now rarely employed ; it consists of two concentric 
curved incisions, joined together at their ends, as seen in Fig. 550. 

There are surgeons who prefer the scissors for making certain inci- 
sions ; Malgaigne always chooses them when the parts may be divided 
at one stroke. 

Subcutaneous incisions are now frequently had recourse to for the 
purpose of shielding the parts divided from contact with the atmo- 
sphere while the reparative process is going on, which experience has 
shown will occur without inflammation. The instrument employed 
for this operation is seen in Fig. 551. It consists of a narrow blade 

Fig. 551. 



Knife for subcutaneous incisions. 

with a long, slender stem connecting it with the handle. In using 
the knife, the blade is introduced flatwise beneath the skin, obliquely, 
under the part to be divided, when its edge is directed against it, and 
by a slow sawing motion the section is effected. The instrument is 
then withdrawn, and the little wound hermetically sealed, either with 
a small piece of adhesive plaster, or a bit of charpie soaked in blood 
or collodion. 



CHAPTER XI. 

BLOODLETTING. 

Bloodletting is an operation performed for the purpose of dimi- 
nishing the quantity of blood in the system, with a view of relieving 
or curing diseases. 

It may be drawn from the arteries, veins, or capillaries ; in the first 
two instances the bleeding is said to be general, and in the latter, local. 

The former plan, now almost abandoned, is had recourse to when 
the amount of blood to be drawn is large, and a decided effect is to 
be made upon the system ; and the latter, when the object is rather 
to deplete a certain organ or part, without reference to the system at 
large. 

There are cases, however, where both methods may be employed 
together with advantage. 

SECTION I. 
GENERAL BLEEDING. 

Venesection, or Phlebotomy. — In former times bleeding was 
performed upon most of the large veins, the operation in each par- 
ticular case being supposed to possess some peculiar advantages ; but 



GENERAL BLEEDING, 



601 



at present the physician, knowing that the general character of the 
effects of loss of blood is the same whether a vein be opened in the 
arm, in the neck, or in the leg, selects the most convenient place 
for the operation, and general experience has decided that to be the 
bend of the elbow. Here the veins are moderately large, superficial, 
and easily dilatable by a bandage placed upon the arm. 

By reference to the annexed wood-cut, Figs. 552 and 553, showing 
the veins of the bend of the elbow, it will be seen that there are five 



Fig. 552. 



Fig. 553. 





Anatomical relation of the veins in the bend of the elbow. 

vessels from which the surgeon may draw blood : the radial vein (1) 
is on the outer side of the forearm, between the skin and superficial 
fascia, is crossed by (17) the spiral cutaneous nerve, a branch of the 
musculo-spiral, and is surrounded by a large number of nervous 
filaments ; the median (8) is about midway of the upper part of the 
forearm, and divides above into two branches, one going to the cepha- 
lic (2), forming the median-cephalic (10), and the other to the basilic, 
forming the median-basilic (11); the anterior (3) and posterior (4) ulna 
are upon the inner side of the arm, and join above in a common trunk 
(5), which empties into the basilic; the median-basilic crosses the 
brachial artery, separated from it by a slip of fascia from the tendon 
of the biceps (13) at the point marked by the figure 12, which rests 
upon the deep fascia ; in Fig. 553 this fascia is turned back, exposing 
the artery beneath; the internal cutaneous nerve (15) divides into 
several branches, which pass across the median-basilic ; the external 
cutaneous nerve (14) pierces the deep fascia, and, dividing into two 
branches, passes behind the median-cephalic, which is surrounded by 
several nervous filaments; the intercosto-humeral cutaneous nerve (16) 
runs along the outer side of the basilic. 



602 BLOODLETTING. 

The veins are more or less surrounded with nervous filaments, so 
that it will be impossible to avoid wounding some of them in vene- 
section, nor does experience teach us that it is of much consequence if 
they are. The proximity of the median-basilic to the brachial artery 
should put us on our guard when opening that vein; and, indeed, if 
there is any choice offered, it should be avoided altogether. The pos- 
terior ulna is sometimes quite large, and offers then the most eligible 
spot for the operation ; though, upon the whole, the median-cephalic 
will be the safest and most convenient vein. 

If a sudden impression is desired to be made upon the system, and 
syncope is induced, the patient should be bled in the erect posture ; 
while, on the contrary, if the full depletive effects of the operation are 
sought, he must lie down. 

After the surgeon has selected the vein he intends to open, which is 
ordinarily visible through the skin (though in children and corpulent 
persons it is not always so, and then the sense of touch will enable us 
to make out the position of the vessel), the circular bandage is placed 
around the arm, some distance above the elbow; this consists of a 
strip of muslin one and a half inch wide and a yard long, and is 
applied by placing its body upon the front of the arm, conducting its 
extremities around the limb, and finally bringing them forwards again 
to be tied in a single bow-knot upon the outer side of the arm. 

The bandage should be drawn sufficiently tight to arrest the circu- 
lation in the veins without disturbing that in the arteries ; the sur- 
geon then takes the lancet by its blade between the thumb and index 
finger, while the middle finger, resting upon the forearm, supports the 

hand, as seen in Fig. 554 ; with 
the left hand the forearm is 
grasped in such a manner that 
the corresponding thumb may 
be used to steady the vein, while 
it is being punctured. The point 
of the thumb-lancet is now thrust 
forwards obliquely, by simply 
extending the thumb and fin- 
ger, into the cavitv of the vein, 

Mode of holding the thumh-lancet in bleeding. ° , . , . , -i . 1 i 

which is known by the absence 
of further resistance to the progress of the instrument, and then with- 
drawn by slightly elevating the point to enlarge the orifice to the 
desired extent. If the operation is well done, the blood will flow 
in a continuous stream, and should be caught in a common basin, or 
in one of those graduated vessels especially made for this purpose, 
and called a " palette." 

Should the blood not flow freely enough, the patient may be directed 
to grasp something in his hand, and to close and relax the fingers 
alternately. The exit of the blood may be hindered by the loss of 
parallelism between the incision in the skin and wall of the vein, 
caused by some movement on the part of the patient ; to remedy this 
the limb should be restored, as nearly as possible, to the position in 
which it was when the incision was made ; or a little clot of blood or 










GENERAL BLEEDING. 603 

granule of fat may come between the lips of the little wound ; they 
must be removed with the point of a probe or a pair of forceps. In 
case the ligature upon the arm is drawn so tight as to obstruct the 
passage of the blood from the arteries to the veins, it must be 
promptly loosened until the blood issues freely. The desired amount 
of blood having been drawn, the surgeon places his left thumb over 
the incision, removes the circular bandage from the arm, which should 
be cleansed from blood with a moist sponge, and slips beneath the 
thumb a small compress an inch square by half an inch thick, made 
of a piece of linen folded ; the compress is secured in position by the 
figure of 8 bandage of the elbow, taking care to draw its lower con- 
volutions tighter than the upper ones that efficient pressure may be 
made upon these veins anastomosing with the vessel opened. The 
arm is now flexed at a right angle, and supported in a sling depend- 
ing from the neck, for thirty-six or forty-eight hours, when the wound 
will be found cicatrized. 

Should it be necessary to repeat the bleeding within the twenty-four 
hours, the same vein may be again opened with the point of a probe ; 
or if this has been anticipated, a little piece of simple cerate placed 
between the margins of the incision will prevent its healing, upon the 
removal of which the blood will flow freely ; but it is a better plan 
always to make a fresh incision. 

The spring-lancet is sometimes employed in venesection ; the instru- 
ment consists of a blade or fleam inclosed in a metallic case, and acted 
upon by a strong spring ; when in use the blade is drawn up with 
the handle projecting above it until its point is above the lower edge 
of the case, in which position it is held by a trigger, and not permitted 
to be driven down unless the button upon the side of the case is 
pressed upon. The arm having been prepared in the same manner as 
in the previous case, if the vein is superficial the edge of the fleam 
should be held a little above the skin ; but, on the contrary, if it is 
deep seated, the point of the 

fleam ought to touch the sur- Fi S- 555 - 

face, in order that the cavity 
of the vessel may be surely 
reached; the blade is then 
driven into the vein obliquely 
by pressing the button of 
the spring, and quickly with- 
drawn. 

Some accidents have fol- 
lowed venesection which re- spring-iancet. 
quire notice in this place, as 

great alarm has often been caused the patient, where there has been 
no occasion for it, by some unusual complication of little moment ; 
for instance, the cutaneous incision may be very narrow, or lose its 
parallelism with the perforation in the wall of the vein, so that the 
blood escapes into the cellular tissue, and gives rise to an ecchymosis 
several inches around the puncture ; the blood in this case will be 
absorbed in three or four days. From the same causes the blood may 




604: BLOODLETTING. 

coagulate around the vein, forming a tumor called a thrombus, which 
also usually disappears without any bad consequence, though it may 
excite inflammation and suppuration, and demand the use of the lancet 
to evacuate the pus. 

As the veins are surrounded more or less with nervous filaments, 
some pain may be caused in irritable subjects, which may be re- 
moved by the application of the watery solution of opium ; convul- 
sions and tetanus have been stated to have originated from the 
same cause. 

As inflammation of the lips of the wound, phlegmon, erysipelas, 
and angeioleucitis, may happen from special causes in any sort of 
wound, they are simply mentioned here as having been occasionally 
seen to follow venesection. 

Phlebitis is always a serious complication of wounds, and may 
occur in phlebotomy; the veins become hard like cords, and the 
whole limb cedematous. The proper remedies for phlebitis are the 
application of leeches, and, after their removal, narcotic poultices. 
It has been recommended to tie the vein above the puncture to pre- 
vent the pus getting into the circulation ; with the same view Aber- 
nethy advised the vessel to be divided instead of ligatured ; free inci- 
sion at the seat of the wound, combined with pressure, will also be 
found advantageous. 

Puncture of the tendon of the biceps muscle has also been pointed 
out as a redoubtable accident upon insufficient grounds. 

Wounding the brachial artery in venesection has often occurred, 
and may result in either traumatic aneurism, or aneurismal varix ; 
the blood, in the former instance, being poured out into the surround- 
ing cellular tissue, and in the latter into the cavity of the vein 
through the orifice made in its posterior wall by the lancet. In the 
aneurismal varix the blood will issue in jets, or per saltum, as it is 
called, and be of a scarlet color, and somewhat frothy. Pressure upon 
the brachial artery above arrests the hemorrhage at once ; but not at 
all, or very slowly, if the pressure is made upon the entire circum- 
ference of the limb. The pressure should be exerted upon the artery 
in the axilla, that no mistake can occur from its bifurcation taking 
place high up the arm. From these symptoms, if it should be ascer- 
tained that the artery has actually been pierced with the lancet, the 
arm should be inclosed in a roller bandage from the fingers to the 
shoulder, and a graduated compress placed over the puncture, with 

Fig. 556. 
bb 




Mode of arresting hemorrhage from the brachial artery at the bend of the elbow, after venesection. 

its apex downward, in the manner shown in Fig. 556 ; a, is the 
artery, and b, b the compress. To sustain the compress, apply over 
it a figure of 8 bandage pretty firmly. 






GENERAL BLEEDING. 



605 



By this treatment it sometimes happens that the wound in the 
artery cicatrizes in three or four days, and no further trouble is expe- 
rienced ; under other less favorable circumstances, a pulsating tumor 
is formed, which will demand an incision to be made over the bleed- 
ing artery, and a ligature applied above and below the wound. 

Both the salvatella and cephalic veins of the hand have been 
opened in venesection. A circular bandage placed around the wrist 
with sufficient firmness, will cause them to swell sufficiently, so as 
to be easily punctured with the lancet. Should the ligature not 
render them prominent, the hand may be soaked a short time in warm 
water. There are no arteries in the way, and the only caution neces- 
sary is to avoid wounding the sheaths of the extensor tendons. When 
the radial artery, instead of following its usual course, mounts over 
the extensors of the thumb, it will be found running parallel with the 
cephalic vein. 

The cephalic vein of the arm is found between the deltoid and 
pectoralis major, and may be exposed by an incision an inch long in 
front of the shoulder, over the inter-muscular space. Yelpeau re- 
commends the vein to be sought just above the inner condyle, where 
it is more superficial ; bleeding from this vessel is rarely ever prac- 
tised at present. 

It was formerly recommended, in certain cases of cephalic disease, 
to bleed from the external jugular which crosses the neck obliquely, 
lying between the superficial 
fascia and the platysma myoid 
muscle, and empties in the sub- 
clavian behind the clavicle. 
The operation is performed by 
placing over the vein a com- 
press just above the clavicle, 
and confining it in the position 
with a cravat, the body of 
which is laid over the com- 
press, and its tails tied beneath 
the axilla of the opposite side, 
in order to prevent the return 
of the blood in the vessel. (Fig. 
558.) The point that should 
be selected for the puncture is 
just below the middle of the 
vein, where the vessel is largest, 
and surrounded with fewer nervous filaments. The vein must be 
steadied by the thumb (Fig. 557), while the thumb-lancet, held in 
the right hand in the manner we have described, is thrust into its 
cavity in an oblique direction, so as to cut the muscular fibres of the 
platysma at right angles to their course, that their retraction may 
allow a sufficient opening for the blood to flow out freely. A card 
or piece of tin, bent in the shape of a gutter, and placed below the 
point of puncture, will conduct the blood away into a vessel ready 
at hand to receive it. 




Bleeding at the jugular vein. 



606 BLOODLETTING. 

Should the blood not issue with sufficient rapidity, the patient may 
be directed to perform the movements of mastication, which will force 
the blood from the deeper veins into the more superficial ones. 

To arrest the bleeding, place the finger over the puncture, remove 
the compress and bandage at first applied, and put a compress upon the 
wound to which it must be secured by a cravat, the base of which is 
laid upon the neck and shoulder of the opposite side, its tails crossed 
over the compress, and finally tied together beneath the axilla of the 
side upon which the vein was punctured. 

The veins of the foot are small, and therefore ineligible for vene- 
section ; by their junction, however, they form two large trunks, the 
internal and external saphenous, which may be opened with the 
lancet. The external saphenous is situated between the external 
malleolus and the tendo-Achillis, and is in relation with a nerve of 
the same name ; the internal saphenous lies upon the inner malleolus 
between the skin and periosteum ; this vein is larger than the former, 
and is generally selected for the operation. 

To enlarge the veins about the ankle, the foot must be placed in warm 
water, and a circular bandage applied to the leg three or four inches 
above the malleoli, then the most prominent vessel being selected, it 
is steadied with the thumb of the left hand which grasps the foot, 
while the point of the lancet is shoved into its interior with the fingers 
of the right hand, almost parallel with the vessel, in order to avoid 
penetrating the periosteum or bone. The flow of blood may be in- 
creased by keeping the foot immersed in warm water contained in a 
pail, though it has the disadvantage of interfering with a correct 
estimate of the amount of blood drawn; the bleeding may also be 
accelerated by the patient moving his toes. 

When a sufficiency of blood has been obtained, the circular bandage 
is removed, and a compress confined over the wound with the figure 
of 8 bandage of the ankle. 

If the point of the lancet should, by any accident, penetrate the 
bone, the wound may be enlarged a little and the point removed ; 
though should the little fragment of metal be permitted to remain it 
will, perhaps, cause a phlegmon to form, and be finally eliminated 
with the pus. 

Aeteriotomy. — The only artery that has been opened in later 
times for surgical depletion is the temporal, and that is now nearly 
abandoned by most surgeons; the ancients, besides this one, did not 
fear to cut the mastoid, and even the radial. 

If it is ever desirable to perform this operation upon an artery, the 
anterior branch of the temporal is of sufficient size to afford the 
requisite amount of blood, besides possessing the advantages of being 
superficial and easily compressed upon the temporal bone to check 
the hemorrhage; and there are no important parts adjacent that we 
need fear wounding. 

The operation is performed either with a lancet or a bistoury (Fig. 
558). The artery being held by the index and middle fingers, an incision 
is made three-fourths of an inch long, at right angles with its course, 



GENERAL BLEEDING 
Fig. 558. 



607 




r/ f 

Mode of dividing the temporal artery in arteriotomy. 

dividing half the diameter, or thereabouts, Fig. 559. 

of the vessel. The object of this is to pre- 
vent the retraction of the extremities of the 
artery, which would be likely to defeat the 
aim of the surgeon, inasmuch as the orifices 
would then be drawn into the cellular 
tissue, in which the blood would coagulate 
and seal them up. 

When the bleeding has gone far enough, 
the instrument is used again to cut the 
vessel completely through to permit the 
divided ends to retract; a compress is 
placed over the wound and supported by 
a roller bandage, as seen in Fig. 559. 

The artery is usually obliterated in eight 
or ten days, though a traumatic aneurism 
does sometimes result, requiring the ends of the artery to be tied. 




Bandage and compress applied after 
arteriotomy. 



608 BLOODLETTING. 

SECTION II. 
LOCAL BLEEDING. 

Local bleeding is generally performed over, or as near to the 
diseased part as possible, for the purpose of abstracting blood directly 
from it. In some cases, from necessity, the point upon which the ope- 
ration is performed will be more or less remote from the diseased 
organ, as in the abstraction of blood from the temple in diseases of 
the eye, and from the hsemorrhoidal vessels in affections of the brain. 
The first method is by far the most serviceable and the one commonly 
employed in surgical practice. 

Local depletion may be effected in two modes : first, by cupping ; 
and second, by leeching. 

1. Cupping consists in the application to the skin of a bell-shaped 
vessel, now made of glass, technically called a " cup," by rarefying the 
air contained within it by means of heat, or a sort of air-pump. In 
this way the integuments are made turgid and red, and are forced up 
some distance into the cup by atmospheric pressure. 

This action produces a derivative effect by drawing the blood from 
the morbid tissues beneath, whose capillaries are thereby placed under 
more favorable circumstances for restoration to health ; this is called 
dry cupping. 

If a more decided and permanent derivative effect is required, the 
integuments are scarified so that, upon the reapplication of the cup, the 
blood will flow out from the capillaries freely, constituting wet cupping, 
or, as it is sometimes named, cut cups. 

Cupping glasses are usually supplied, by surgical instrument makers, 
of different sizes, holding from one to four ounces, destined for appli- 
cation to the various localities of the body, upon all of which it would 
be impossible to put glasses of the same dimensions. Should these 
not be at hand, however, the ordinary wineglass or tumbler will an- 
swer as a good substitute. 

The person to be cupped should be placed in a convenient position, 
and arranged in such a manner that his clothes may not be soiled with 
the blood ; the skin upon which the operation is to be performed is 
then bared and wiped clean with a sponge dipped in hot water, which 
will at the same time tend to congest the capillaries, and thus render 
the bleeding freer. The operator takes a cup in his hand, and either 
dips it in hot water, or holds it for two or three seconds over the 
flame of a spirit lamp, to rarefy the air in its interior, and quickly 
claps it upon the skin ; a better plan is to moisten the interior of the 
glass with alcohol, or put into it a thin piece of paper dipped in that 
fluid and set fire to before the cup is applied. 

The integuments will rise immediately into the mouth of the glass, 
and present a red, turgid appearance. 

A second mode of rarefying the air inside the cup is with an air- 
pump, which is made with a socket at its extremity to fit the nipple- 
like projection upon the tops of the glasses ; the projection is pierced 
with a small aperture and covered with a little slip of gold beater's 



LOCAL BLEEDIXG. 



609 



skin or oiled silk to serve as a valve, or, as a better arrangement, still 
it bears a stopcock, as seen in Fig. 560. With this instrument the 
air is gradually exhausted from the glass by repeated strokes of the 
piston, until the skin is sufficiently turgid, when the stopcock must 
be turned, and the air-pump removed. 

To do away with the inconveniences of the air-pump, among which 
we may mention as the chief its liability to get out of order, it has 
been suggested to attach an India-rubber ball to the 
top of the cup and make the vacuum with that, by grasp- 
ing the ball in the palm of the hand and alternately 
compressing and relaxing the hold upon it (Fig. 561). 

Whichever plan is pursued, the glasses must not be 
exhausted too much, for if they are, their edges will pro- 
Fig. 561. 



Fig. 560. 






Cupping-glass with India-rubber ball attached. 



Mode of attaching an 
air-pump to the 
cupping-glass. 



bably bruise the skin, prevent the flow of blood, and at the same time 
cause considerable pain. 

To remove the cup it will be necessary simply to cant it a little to 
one side, and with the tip of the finger press the integuments away 
from any point of its rim, which will permit the entrance of air into 
the glass and destroy the vacuum. 

In applying cut cups the same methods are pursued as described 
above, and when the skin is sufficiently con- 
gested the glass is removed and incisions are Fig. 562. 
made upon the reddened surface ; this may be 
accomplished either with the lancet, bistoury, 
or scarificator, the latter being the most expedi- 
tious and least painful manner. This instru- 
ment, as seen in Fig. 562, consists of a square 
metallic case containing from twelve to fifteen 
broad, sharp blades, attached to two stems of 
metal revolving through a quarter of a circle, 
and driven by a strong spring; the depth of 
the cut may be graduated by raising or depress- scarificator, 
ing the blades with the screw-head seen upon 

the top of the instrument; the blades are drawn into the case by: 
39 




610 BLOODLETTING. 

pulling back the lever placed by the side of the screw-head; the lever 
is held by a catch. 

The instrument thus arranged is ready for use, and is laid flat upon 
the surface to be scarified; then, by exercising pressure with the 
thumb upon the little button seen upon its side, the trigger is sprung, 
and the blades driven into the skin. 

After the incisions are made, the glasses are again applied, when 
the blood will readily flow into them in quantity varying with the 
size of the cups and the vascularity of the parts ; perhaps, on an 
average, an ounce will be drawn by each cup, but should it be neces- 
sary these may be reapplied several times, "until the desired amount of 
blood is obtained. A basin of warm water should be at hand, and 
two or three soft towels and sponges; the cups, one after another, are 
then seized in the fingers, and having been depressed upon the side, 
are quickly removed with a sort of scooping motion to catch the 
clotted blood, assisting the operation with a sponge held in the oppo- 
site hand. In this manner the patient's clothes will not be soiled at 
all. The surface may be now gently cleansed with warm water, and 
dried with a towel; generally, no dressing will be required, but 
should the incisions be sore or painful, a soft rag, moistened in glyce- 
rine, or water-dressings, will be the most appropriate applications. 

Cups should not be placed over osseous projections, nor indeed 
upon any surface where there is not a sufficient amount of soft tissue 
to give them ample support. There are other situations where their 
application is manifestly impracticable — as in the interior of cavities, 
upon the eyelids, testicles, &c. Yet even these difficulties have been 
surmounted in some degree by the cups of Toirac, which consist of 
long, narrow glasses, connected by an elastic tube with an air-pump, 
that are capable of being applied to the bottom of any cavity what- 
ever. M. Sarlandiere invented an instrument called a bdelhmUre, 
which combines in its construction the air-pump cupping-glass with 
the scarificator, so that the whole operation of cupping can be accom- 
plished in one application of the instrument. 

Prof. Simpson, of Edinburgh, has used an instrument for cupping 
the interior of the uterus in amenorrhoea ; it consists of an air-pump 
and a perforated tube, sufficiently large to hold several drachms of 
blood, connected together. The tube is curved, and has a ring of 
gutta-percha upon it, rounded in such a manner as to accurately close 
the os uteri when the point of the instrument is in the cavity of that 
organ. 

M. Junod recommended the use of cups sufficiently large to inclose 
portions of the body, as the leg or arm. He employed a copper cylin- 
der, in which the limb was to be placed, and rendered air-tight by a 
strip of India-rubber surrounding the limb and the upper end of the 
cylinder ; to the latter an air-pump is attached to make the vacuum, 
which can be regulated by an instrument connected with the cylinder. 
With this apparatus the most powerful and rapid derivative effects 
can be obtained, that syncope may be induced in a brief space of 
time. 

Leeching. — For the purpose of local depletion, leeches, in many 



LOCAL BLEEDING. 611 

cases, offer decided advantages ; indeed, some parts of the body, from 
their situation within the interior of the natural cavities, peculiarity 
of form, or from diseased condition of their surfaces, cannot be easily 
depleted in any other manner. There are two kinds of leeches em- 
ployed in this country, which it is necessary to be able to distinguish, 
as they differ materially in the amount of blood which they are capa- 
ble of abstracting. The foreign leeches (Sanguisuga officinalis and 
medicinalis) are gathered in Sweden, and several parts of the south of 
Europe, from the marshes and running streams, and imported from 
London and Paris. They vary from two to four inches in length, 
and are marked upon their backs, which vary from a blackish to a 
grayish-green, with six longitudinal ferruginous stripes, the four late- 
ral ones being interrupted with black spots ; the belly, in one variety, 
is of a yellowish-green color, bordered with longitudinal black stripes; 
in the other, of a green color, bordered and spotted with black. Each 
of these animals will draw rather more than a half-ounce of blood. 

The indigenous leech (Hirudo decora) is usually from two to three 
inches long, though it sometimes attains a length of five inches ; its 
back is of a deep green color, with three longitudinal rows of square 
spots, and the belly of a brownish-orange color, irregularly spotted 
with black. The animal does not make so large a wound in the skin 
as the former, and it requires at least six of them to extract one ounce 
of blood. 

The mouth of the leach is placed in the centre of the anterior disk, 
and is composed of three cartilaginous jaws, each armed with two 
rows of fine teeth meeting in such a manner as to make a triangular 
wound in the integuments. 

In applying the animals to the skin, care should be taken to have 
it well cleansed of all foreign matters clinging to it either from the 
applications that may have been used, or from the secretions; the 
hairy parts of the body should be thoroughly shaved, so that the hair 
may neither interfere with the action of the leeches nor become 
clotted with blood. 

The leeches are then put on inclosed in a tumbler ; or, if there are 
many of them, laid first upon a napkin spread upon the palm of the 
hand, and then clapped to the skin, the fingers being used to hold the 
edges of the cloth all around, so that they may not escape. Vigorous 
leeches will generally take hold upon the skin without delay ; but 
should they not do so, milk, cream, or sweetened water smeared over 
the surface will almost always tempt them to bite; some persons 
obtain a little blood from the tip of the finger by pricking it with a 
needle, which they rub upon the skin with the same object. 

An increased activity may be excited in the leeches by covering 
them with a cupping-glass, and rarefying the air contained in it by a 
few strokes of the air-pump. Another mode recommended as very 
efficient is to put the leeches first in a tumbler half full of cold water, 
and by a quick movement invert it over the part to be depleted ; the 
animals will seek the warm skin immediately, and quickly attach 
themselves to it, when the water may be permitted to run from the 
glass upon cloths placed to receive it. 



612 BLOODLETTING. 

To bring leeches in contact with the interior cavities, the vagina or 
rectum, for instance, a speculum should be first introduced, then a 
leech is placed in a glass tube, or one formed from paper or a card ; 
and when its point is at the spot where the animal is to bite, the latter 
should be shoved forward against it by a pencil, or little stick running 
through the tube ; the tube may also be employed to bring the mouth 
of the leech in contact with any part of the buccal or nasal mucous 
membranes. 

When the leeches are gorged, they will generally relax their hold 
and drop off, though should it be necessary to arrest their action at 
an earlier period than that, a little salt, snuff, or ashes, may be sprinkled 
upon them ; no tractile force should be exercised for this purpose, as 
it is calculated to damage the jaws of the leech, and leave a portion 
of the suctorial apparatus sticking in the skin. 

It has been proposed, in order to increase the rapacity of the leech 
for drawing blood, to clip off the point of his tail, after he is gorged. 
The operation is rarely successful, and always fatal to the animal ; 
besides, after the leech falls off, the bleeding may be continued by the 
application of warm water-dressings, poultices, or a cupping-glass, so 
that really there is no necessity for this barbarous treatment. 

In some instances the hemorrhage continues after the leech-bites 
have been exposed to the air without any of these warm applications, 
and to such an extent as to call for the interference of the surgeon. 
Generally, the compression exercised upon the wounds by a little cone 
formed by twisting a piece of lint or charpie, and a roller bandage, 
will suffice to stop the bleeding. Another efficient remedy is the in- 
troduction of the fine point of a stick of nitrate of silver into the 
bite ; others have found it necessary to employ the actual cautery or 
the twisted suture, before the hemorrhage could be arrested ; such cases 
must be rare, and mostly occur in persons of the hemorrhagic diathesis. 

Saturated solutions of alum, of sulphate of zinc, the liquor of the 
persulphate of iron, and other astringents, are also efficient applica- 
tions, and may be used upon pledgets of lint thrust into the wound 
with a needle, and supported with a compress and roller. 

Accidents have happened from the leeches getting into the stomach 
and rectum, as in the cases observed by Baron Larrey, where they 
were swallowed with the water that soldiers drank from the pools in 
Egypt. They have also been known to detach themselves from the 
nasal and buccal mucous membranes, and escape into the stomach. 
The remedy in these cases is the prompt administration of salt water 
or vinegar in the form of a drink, or as an injection if the animals 
have crawled into the rectum. 

Wounds of the temporal artery and external jugular vein have 
been seen to result from leech-bites; compression will succeed in 
arresting the hemorrhage from those vessels. 

The classes of cases in which leeching is employed, are in the treat- 
ment of the inflammatory diseases of infants where abstraction of 
blood is indicated, and in whom general bleeding cannot be performed 
with safety ; and in the local inflammations of the various organs of 
the body, in which leeching is both depletive and counter-irritant. In 



LOCAL BLEEDING, 



613 



563. 



phlegmonous erysipelas it has been advised to abstain from the use 
of leeches, upon the supposition that their bites would add to the 
severity of the malady ; but the objection does not appear to be sus- 
tained by actual observation. 

The arrangement and care of leeches is an important matter, and 
deserve a moment's consideration. After the animals have been once 
applied, the blood may be removed from their stomachs by throwing 
them into a solution of common salt, sixteen parts to a hundred parts 
of water ; then remove them one by one, and holding the animal by the 
tail in water that feels hot to the hand, draw him gently through the 
fingers to expel the blood. After this treatment they should be placed 
in clean, fresh water, which must be changed once a day ; on the eighth 
day, they may again be used when required. 

Leeches are liable to epidemic diseases, which destroy them rapidly ; 
and the best means to preserve them from these, as well as to sustain 
them in vigorous health, is to place them under those natural condi- 
tions, as near as can be, in which they are found. For 
this purpose numerous methods have been suggested, 
of which the simplest is, to select a jar in which soft 
clear water is put, throw the leeches into this, and keep 
the jar covered with a linen cloth ; the water must be 
changed twice a week in winter and once a day in sum- 
mer, care being taken that all slimy matter adhering to 
the animals is removed. 

In a state of nature leeches clean themselves of this 
slimy material, upon the freedom from which their 
health so much depends, by crawling through the 
interlacing mosses of the marshes in which they live. 

To furnish a condition analogous to this, it will be 
advisable to put in the bottom of the jar some earth, 
or, better still, clumps of peat. 

Mechanical Leeches. — An effort has been made, 
without much success, however, to furnish an instrument 
for local depletion, resembling in its action that of the 
leech. The figure (563) illustrates the manner in which 
this instrument may be made. 

It consists of a suction-tube (E) and an air-pump (A) 
connected by the screw B ; C is a rod working air- 
tight through the cap of the suction-tube, and armed 
at its lower extremity with three sharp points (D) to puncture the 
skin. 



Kolbe's mechani- 
cal leech. 



614 EXTRACTION OF THE TEETH 



CHAPTER XII. 

EXTRACTION OF THE TEETH. 

The extraction of the teeth claims a place in a treatise of this 
character, as it is an elementary operation for the performance of 
which country practitioners and the medical officers of the army and 
navy are often called upon. In cities, a special class of persons are 
commonly charged with this duty, who by continual practice acquire 
sufficient manual dexterity to save the patient a good deal of suffering, 
and also, perhaps, from accidents of a serious character which have 
often happened at the hands of ignorant persons. 

The extraction of a tooth, though so simple in appearance, requires, 
nevertheless, some surgical knowledge and dexterity for its correct 
performance; for an unskilful hand has produced fracture of the 
alveolus and antrum maxillare, wounds of the gums, and in some 
cases, serious nervous disturbance in delicate females ; hence, every 
surgeon, who may be liable to be called upon to perform this operation, 
should at least familiarize himself with the proper method of accom- 
plishing it. 

From the manifest inadaptability of the "Key of Garengeot" to the 
extraction of the incisor teeth, the forceps have always been used for 
this purpose ; and since 1830 so many improvements have been made 
in their construction, that now operators almost exclusively employ 
them upon the molars as well. 

Forceps require more skill in their use than the " key," but they 
are at the same time a safer instrument, inasmuch as the power exerted 
upon the tooth is mostly parallel with its length, or the direction it 
takes in being dislodged, while the action of the key is exactly the 
reverse. 

For the proper performance of the operation, at least seven pairs of 
forceps are required. One pair for the upper incisors and cuspidati ; 
which, as seen in Fig. 564, have straight grooved jaws sufficiently thin 

Fig. 564. 




Forceps for the upper incisors and cuspidati 



at their points to be introduced between the gum and neck of the 
tooth ; the handles should be strong enough not to spring in the hand 



EXTRACTION OF THE TEETH. 



615 



when firmly grasped ; the extremity of one of them is turned up so 
as to prevent the hand slipping by hooking around its ulnar border. 
The necks of the lower incisors being narrow, the forceps intended 
for them should have very narrow points, and the jaws curved below 

Fig. 565. 




Forceps for the lower incisors and cuspidati. 

the articulation so as to form an angle of twenty degrees with the 
handles (Fig. 565). 

For the extraction of the bicuspidati of both jaws the forceps seen 
in Fig. 5Q6 are well adapted ; their points are broadly grooved, so as 
to take a good hold of the tooth. 

Fig. 566. 




Forceps for the bicuspidati. 



For the lower molars but one pair of forceps will be required ; they 
should be strong, and curved at the beak in front of the articulation ; 
each point has two grooves, with a projecting tip between them, so 

Fig. 567. 




Forceps for the lower molars. 

situated that in grasping the tooth the points will lodge upon either 
side of it below the bifurcation of the roots. The handles may be 
straight, as seen in Fig. 567, or, what is better, have one of them 
curved at its extremity so that the hand may not slip. 

From the anatomical arrangement of the roots of the upper molars 
two pairs of forceps will be necessary, one pair for those upon the 
right side, and the other for those upon the left. Their jaws are curved 
in front of the articulation, and the handles behind it; it will be 
seen in the annexed wood-cuts, Figs. 568, 569, that that point which 
is to be applied to the palatine face of the neck of the tooth is simply 
concave, while the opposite one is both grooved and pointed to catch 
between the bifurcation of the roots upon its external side. 



616 



EXTKACTION OF THE TEETH 
Fig. 568. 




Forceps for the right upper molars. 
Fig. 569. 




Forceps for the left upper molars. 



From the position of the dentes sapientise far back in the mouth a 
peculiarly constructed instrument is called for, such as is shown in Fig. 
570 ; the jaws resemble in form the letter Z, and enable the surgeon to 

Fig. 570. 




Forceps for the last molars. 

get a firm grasp upon these teeth, without being interfered with by 
the teeth of the lower jaw. 

For the purpose of removing the roots of the teeth the narrow 
pointed forceps above described will answer very well, though con- 
siderable assistance may be derived from the screw and elevator, the 
forms of which are so well known as not to require any special descrip- 
tion in this place. 

In applying the forceps the points of their jaws must be shoved 
well in between the gums and neck of the tooth, and just sufficient 
amount of pressure made upon the handles to insure the instrument 
from slipping; then, if it is a front tooth that is being extracted 
(Fig. 571), move the forceps backwards and forwards two or three 
times; give them a little rotatory movement, and lift the tooth up- 
wards from its socket. In extracting the molars the forceps must be 
moved laterally to loosen the tooth, and the force then applied in a 
perpendicular direction with its axis. 



EXTRACTION OF THE TEETH, 



617 



Some have deemed the preliminary use of a lancet necessary in 
separating the gums from the teeth ; but this is not at all required if 
the jaws of the forceps are well forced up around the neck of the tooth 
(Fig. 572). 

The instrument sometimes employed in Fl g- 5 7l. 

extracting teeth called the "key" was in- 
vented by Grarengeot : and since his time it 
has undergone various modifications, both 
in the shape of the stem, and in that of the 
fulcrum. 

The "key-bit" should be of sufficient width 
to be placed upon the gums at an advanta- 
geous distance from the tooth to be extract- 
ed. If too near this, the crown of the tooth 
will be broken ; if too far, the alveolus will 

Fig. 572. 





Forceps in extracting upper molars. 



Forceps in extracting lower incisor. 



suffer a similar fate. To the " bit" the hook is to be secured with 
a pin provided with a thread, so that the former cannot become 
detached from the fulcrum. The hook is curved, and terminates 
at its point in an edge about one-sixteenth of an inch in width, with 
a little notch at its centre dividing the edge into two little points, 
which are intended to prevent the instrument slipping from the tooth. 
The stem of the key is curved where it joins with the fulcrum, so 
that it may not be interfered with by the front teeth when we are ope- 
rating upon the molar. The handle is fitted crosswise the stem, and 
secured to the latter by a milled-head screw, removable at pleasure, 
so as to make the instrument more portable, and if there is need, per- 
mit the handle to be used in connection with the stem of any other 
instrument. 

By withdrawing the pin from the " key-bit" the hook may be de- 
tached and changed to either side of the fulcrum, as the necessities of 
the case require. Two or three hooks of different sizes should always 
accompany the instrument, adapted to the varying dimensions of the 
tooth. 

In operating with the key, we select a hook of the proper size, and 
fasten it to the fulcrum, taking care to envelop the latter with a piece 
of bandage or the end of a napkin, so that the gums may not be 
wounded by its pressure. 

The handle of the instrument is held in the right hand, while with 
the index finger of the left we guide the hook to the tooth we wish 
to remove, and force its edge between the gum and inner surface of 
its neck near the edge of the alveolus, as seen in Fig. 573 ; then by 
a gentle twisting movement the tooth is made to move towards the 




618 CATHETERISM. 

Fig. 573. fulcrum, and at the same time upwards ; when com- 

pletely loosened in this manner, by elevating the key 
the tooth is removed. 

As a general rule the fulcrum is placed upon the 
outside of the gum ; though should the tooth have a 
decided curve towards the tongue, or have its inner 
wall destroyed by caries, the fulcrum may be estab- 
lished upon the inner side of the dental arch. 

Extreme pain is almost always caused by the extrac- 
tion of teeth, whether performed with the forceps or the 
Mode of using the key, which usually disappears in a short period, but 
key in extracting may last for several days. Fractures of the alveolus 
teeth - sometimes occur ; if the fragment is small, it will gene- 

rally escape after the lapse of a few days ; a large piece 
of bone should be supported in its natural position, and it will soon 
become reunited to the jaw. By a bungling operator, the teeth 
adjacent to the one he wishes to remove may be loosened, or even 
broken. 

It rarely happens that there is much bleeding after extraction, 
though cases are recorded in which the hemorrhage was obstinate ; 
should such an instance be encountered, a good plan to pursue is as 
follows : Soak a small ball of cotton or charpie in the tincture of the 
perchloride of iron, and press it into the tooth socket firmly ; over 
this place other pieces of the same material until the alveolus is quite 
full, and the plug projects above the crowns of the two adjacent teeth ; 
then mould a piece of sheet lead over the plug, and after bringing the 
jaws firmly together, sustain them in this position by one of the 
bandages for the head and jaw already described. 

Some persons have found it necessary to cauterize the alveolar 
cavity with the point of a hot wire. 



CHAPTER XIII. 

CATHETERISM. 

Cathetekism is the introduction of the catheter, sound, or bougie 
into any of the natural passages of the body, such as the urethra, 
Eustachian tube, or the nasal duct. When the word is used without a 
qualifying adjective, it simply defines the operation as performed upon 
the urethra. 

Yarious instruments are used in executing this operation, according 
to the position and anatomical structure of the canal ; though the 
results obtained in different cases are often identical: thus, the 
catheter may be introduced into the bladder and stomach for the 
purpose of removing their contents ; or, again, with the view of over- 
coming a constriction or narrowing in the urethra or oesophagus. It 



CATHETERISM OF THE NASAL DUCT, 



619 




Diagram showing the anatomical rela- 
tions of the canalicnli with the nasal duct : 
2, puncta ; 3, 3, canaliculi terminating by 
a common trunk (4) into the lachrymal 
sac (5). 



Fig. 575. 



becomes necessary sometimes to inject Fl 'g- 574 - 

fluid substances into the Eustachian 
tube, nasal duct, trachea, and bladder. 

Important information is, likewise, 
obtained by this operation, of the con- 
dition of the walls of these passages; it 
declares the presence or absence in them, 
of foreign matters, as well as morbid 
alteration in their caliber. Introduced 
into the bladder, the sound serves as a 
guide for the knife in lithotomy ; and 
with a peculiarly constructed catheter 
the surgeon is enabled to plug the nares 
so as to arrest profuse hemorrhage. 

Catheterism of the Nasal Duct. — 
The nasal duct, lodged in the lachry- 
mal canal, commences at the inner 
canthus of the eye in a slight enlarge- 
ment, the lachrymal sac, into which the 
canaliculi empty — sometimes separately, 
but in almost all cases by one orifice, as seen in Fig. 574 — 
and terminates in the inferior meatus of the nose in a slightly 
expanded orifice near its floor, and about six lines from the 
orifice of the nostril ; it is about one-half inch in length and 
two lines in diameter, and slightly curved upon itself, the 
convexity being outwards ; the canaliculi are about one line 
wide and three lines long, commencing upon the inner mar- 
gin of the tarsal cartilages, the superior taking a direction 
upwards and inwards, the inferior downwards and inwards. 

The operation may be performed through the puncta, 
through an incision at the inner canthus into the lachrymal 
sac, or through the inferior orifice of the duct, its object 
being in each case to dilate the nasal duct, and thus to restore 
the natural flow of the tears through it. 

In the first instance, the operation is performed with deli- 
cate flexible probes of silver, invented by the French sur- 
geon Anel. It is accomplished in the following manner : 
►To dilate the upper canaliculus, the tarsal cartilage is seized 
between the thumb and index finger, and slightly drawn 
out; the probe is held in the right hand like a pen, with its 
point in the superior puncture, and pressed gently upwards 
about two lines, when the probe is brought parallel with the 
ciliary border of the upper eyelid ; shoved inwards a little ; 
then gradually raised vertically in a line with the supra- 
orbital notch, and pressed inwards and downwards into the 
lachrymal sac. The duct may be entered through the lower 
canaliculus by passing the point of the probe downwards 
about one-tenth of an inch into the inferior puncture, then 
inwards and slightly upwards. 

When the nasal duct is to be dilated through an artificial Anei's probe. 



620 



CATHETERISM, 



orifice, catguts and styles are employed, such as are seen in Figs. 576, 
577, 578. The styles are made of silver or lead, and the sizes used are 



Fig. 576. 



Fig. 577. 



Fig. 578. 



Styles for dilating nasal duct. 

to be gradually increased from the smallest to the largest, as the duct 
yields. Fig. 578 shows a style that may be extemporized at any moment 
from a piece of lead-wire six to eight lines long, of the proper dimen- 
sions, rounded at one end and bent at the other. 

Fig. 579. 




Morgan's probe for dilating the nasal duct. 

The instrumeut for dilating the duct from below is seen in Fig. 579. 
It is to be introduced in the manner we have already described at 
page 107, for the catheter of Gensoul. 

Catheterism of the Eustachian Tube. — Catheterism of the 
Eustachian tube is now performed as a diagnostic means, and for the 

Fig. 580. 




Flexible tube, and the Eustachian catheter into which it fits. 

introduction of air into the cavity of the tympanum. For the latter 
purpose, the instrument seen in Fig. 580 is employed. 



PLUGGING THE POSTERIOR NAEES. 621 

The catheter is introduced by holding it lightly between the thumb, 
middle, and index fingers, and passing its point backwards along the 
floor of the nares, with the convexity upwards. When about four 
inches deep, and the point has reached the veil of the palate, indi- 
cated by the acts of deglutition which it excites when it arrives at 
that place, the extremity of the catheter should be rotated against the 
outer wall of the pharynx to enter the orifice of the Eustachian tube, 
which is situated about eight lines above the plane of the floor of the 
nares. To assure himself that the beak of the instrument is in the 
orifice of the tube, the surgeon should gently pull the catheter for- 
wards, when a feeling of resistance will be perceived if the operation 
is successful. The point of the elastic tube is now fixed to the cathe- 
ter, which is to be sustained in the left hand, while the surgeon takes 
the other end of the tube in his mouth, and gently forces air into the 
cavity of the tympanum. 

This operation is performed in certain cases of deafness for the pur- 
pose of removing mucus from the Eustachian tube, and liberating the 
lips of its faucial orifice after appropriate remedies have been employed 
to diminish the hypertrophy of the mucous membrane lining it. 

Plugging the Posterior Nares. — Plugging of the posterior 
nares is a species of catheterism which we sometimes have recourse 
to, to control hemorrhage from the nasal fossae, when either by its 
quantity or duration it becomes threatening, and after other simpler 
means have failed. 

The operation is usually performed with a special instrument called 
the " sound of Belloc." It consists of a silver tube about seven inches 
long, curved at one of its extremities; the other extremity has a ring 
soldered to it corresponding with the side of the curve, which enables 
the operator to judge exactly where the point of the instrument is 
after it is introduced ; through the tube a steel spring runs for half 

Fig. 581. 



W 




Belloc's sound. 



its length, having an eyed point, and fastened at the other end to a 
metallic stem (b), by means of which it may either be projected from 
or withdrawn into the tube. 

When this instrument is not at hand, an ordinary gum catheter can 
be used in the following manner : Take a doubled' thread, and tie its 
lopp or bight to the point of the catheter, which should be furnished 
with a wire stylet, so that it may maintain the curved form impressed 
upon it; then, holding the catheter with the free ends of the threads 
in the right hand, pass its beak along the floor of the nares, with its 



622 



CATHETEKISM, 



point downwards, until it reaches the pharynx, when the stylet should 
be withdrawn a little, and the patient then directed to breathe forcibly; 
the point will then come sufficiently forwards to be grasped in a pair 
of forceps and drawn into the mouth ; the thread should now be 
loosened from the catheter, and the latter withdrawn, when a plug of 
the proper dimensions, having a single thread attached to it, may be 
fastened in the loop of the doubled thread. A simple thread rolled into 
a little ball and placed in the nostrils will be drawn into the pharynx 
by directing the patient to make short and quick inspiratory actions 
with the mouth closed ; the end of the thread may then be seized and 
drawn into the mouth. 

Another expedient is to join a little sac of thin bladder or gold- 
beater's skin to the point of a catheter, and thrust this into the posterior 
nares, after which it may be distended with air or water. Similar to 
this is the instrument of M. Gariel, consisting of a gum-elastic tube 
capable of being dilated at one extremity into a size sufficient to fill 
up the posterior nares, and furnished at the other with a stopcock. 
After it is introduced into the nose, the tube is dilated either with air 
or water. 

In using the instrument of Belloc, two compresses are to be made 
from patent lint or other suitable material, and of convenient size, one 
for the posterior nares, and the other for the orifice of the nose ; to 
the centre of the former a double thread is attached, intended to be 
drawn through the nares, and also a single thread, destined to hang 
from the mouth, and by which the compress is withdrawn. Thus 
prepared, the surgeon now passes the "sound" through the nostril into 
the pharynx, and then thrusts the spring forwards by the metallic 
stem, which, from its curved form, enters the mouth from behind, and 



Fig. 582. 




Mode of plugging the naves. 



may be seized with the fingers and held while the double thread is 
being passed through its eyed point ; after this is done, the spring is 
drawn into the canula, and the instrument removed, bringing along 



CATHETERISU OF THE (ESOPHAGUS. 



623 



with it the double thread, which must be held in the left hand, and 
gentle traction made upon it, while the surgeon with his right index- 
finger guides the compress through the mouth and up behind the soft 
palate, leaving the single thread hanging from the mouth. The second 
compress is now placed over the meatus of the nose, and the double 
thread tied upon it. In this manner the hemorrhage is arrested ; for 
the nares, being plugged anteriorly and posteriorly, become filled with 
blood, and pressure is thereby brought to bear upon the bleeding 
vessels. At the end of forty-eight hours the flow of blood will have 
been checked, and the plug may be removed by untying the thread 
over the anterior compress, and drawing upon that one in the mouth. 

M. Bretonneau prefers the kite-tail plug to all other means of plug- 
ging in epistaxis. It is formed of a thread about forty feet long, 
to which, at intervals of about six or seven 
inches, pieces of carded cotton (to be oiled 
before using the plug) are attached. 

Catheterism of the (Esophagus. — Cathe- 
terism of the oesophagus becomes necessary 
under two conditions : first, when there is stric- 
ture ; second, when we wish either to evacuate 
the contents of the stomach, or to introduce 
into it liquid aliments. 

In the first case we use bougies made of 
lead, silver, or gutta-percha. M. Boyer em- 
ployed silver sounds successfully. These in- 
struments should be of different sizes, properly 
curved, and of sufficient length to reach be- 
yond the stricture (Fig. 583). 

To remove the contents of the stomach, or 
to inject nutrient fluids into it. a long flexible 
tube is employed, made of India-rubber or 
waxed cloth ; one of its ends is furnished with 
a well rounded and fenestrated tip of gutta- 
percha, the other is connected with a small 
metallic force-pump ; the pump itself is con- 
structed with ball-valves, which are the most 
durable kind and least likely to get out of 
order, and has also attached to the side of its 
barrel a second tube of the same material as the first. In using the 
instrument, the oesophageal tube may be introduced into the stomach 
either through the nostrils or mouth. 

To pass the tube through the nose, the larger meatus, if there is any 
difference in their size, should be selected ; the patient is seated in a 
chair, or may lie upon his back, and is directed to extend the head in 
order to diminish the angle formed by the nares and the pharynx; 
then the tube, held in the right hand, is carried along the floor of the 
nose, keeping it well against the septum, to prevent its point catching 
against the turbinated bones ; when it has reached the pharynx the 
patient must open his mouth widely to enable the operator to press the 
end of the tube with his index finger towards the left side that it may 
go more directly into the superior orifice of the oesophagus, the open- 




stricture of the gullet, at its 
most ordinary position, -with a 
bougie introduced by the mouth. 



624 CATHETERISAl. 

ing of tlie larynx being nearer the median line. The instrument must 
now be passed slowly and gently into the stomach, which will be 
known by its being suddenly arrested by the pressure of the point 
upon the walls of that viscus. 

The operation is but little difficult to execute, and with patience 
may be readily accomplished when the tube may be kept in the 
stomach as long a period as is required for the attainment of the object 
in view by fastening it with threads, after the manner of a catheter, 
to a T bandage of the nose. 

If there is choice left, the mouth should always be selected for the 
introduction of the tube, inasmuch as this cavity, besides being more 
capacious, by simply throwing back the head, may have its axis 
brought in a line with that of the oesophagus. With the head in this 
position, the surgeon depresses the tongue with his left index finger, 
and holding the tube in the right hand he passes it into the throat ; the 
irritation of the point of the instrument will at first cause the patient 
to retch, or even vomit ; but the parts, in a brief period, become accus- 
tomed to its presence, and it may be pressed gently onwards to the 
stomach, avoiding the superior orifice of the larynx, and taking care 
not to perforate the walls of the oesophagus, which might happen should 
they have undergone softening from carcinomatous or other morbid 
conditions. 

The tube may be kept in for some time, but it is more embarrassing 
to the patient than when introduced by the nose. 

If the object is to evacuate poison from the stomach, the pump is 
now attached to the tube, and a quantity of water injected : this is re- 
moved, and more fresh water introduced ; and this in turn pumped out; 
until by the repetition of the process the fluid removed is perfectly 
clean and clear, taking care never to empty the stomach entirely, as 
there is a risk of the mucous lining of the organ being damaged. In 
injecting fluids into the stomach the operator should be certain that 
the tube is in that viscus, for it has happened in several cases that in- 
stead of putting it into the stomach the lungs have been flooded, in one 
instance upon record with chalk mixture, and in another with soup. 
This is more likely to happen if the patient, during the operation, is 
insensible. 

To prevent the tube being bitten, a wooden gag with a hole through 
it may be introduced between the teeth. 

Catheteeism of the Larynx and Trachea. — Dr. Horace Green, 
of New York, has established both the practicability and the utility 
of catheterization of the larynx. 



r 



Fig. 584. 



Sponge probang. 



He employs the instrument seen in Fig. 584, consisting of a stout 
whalebone handle about ten inches long and bent at its extremity, which 



Catheterism of the urethra. 625 

is mounted with a pellet of soft sponge, at an angle of nearly 45°. The 
operation is performed by seating the patient in a chair with his head 
thrown back and the mouth as widely open as possible ; the surgeon 
presses the tongue down with a depressor, and holding the probang 
in his right hand, glides the sponge towards the epiglottis, at the 
same time directing the patient to take a deep inspiration, when the 
point of the instrument is slipped into the larynx. It needs to rest 
there but a single moment, and should be quickly withdrawn. The 
cases in which the operation has been performed are syphilitic and 
tubercular ulceration of the larynx, excrescences about the vocal cords, 
and oedema of the glottis. The application usually made use of is a 
solution of the crystallized nitrate of silver in water, of the strength 
of forty to sixty grains of the former to an ounce of the latter. 

In the hands of Dr. Horace Green the probang has been carried 
into the trachea, and even as far as the bronchi. 

Catheterism of the Large Intestines. — Catheterism of the large 
intestines is employed to relieve flatulent distension of the colon, and 
in stricture of the rectum. 

In the first instance the long flexible tube of the stomach-pump will 
answer very well ; it should be well oiled, and gently pushed into the 
rectum to as high a point as is requisite to remove the accumulated 
gas. I have on several occasions introduced this instrument to a 
distance of two feet into the bowel without any difficulty, and in very 
thin persons it may be felt in the transverse colon ; if cold water is 
thrown in the patient first experiences its impression at that point of 
the colon corresponding with the point of the tube ; showing clearly 
that the tube has not been doubled upon itself. 

In the treatment of stricture of the rectum bougies of India-rubber, 
metal, wax, or wax-cloth are used ; also several special kinds of dila- 
tors. 

Their introduction should be accomplished with the greatest care, 
the smallest instrument being first employed that will pass the stric- 
ture, the size being insensibly increased as the constriction yields. 

To overcome some of the objections to the bougie special dilators 
have been invented, which, when closed, form a slender stem that may 
easily pass the stricture, and then can be enlarged to any dimension 
by turning a screw placed upon the handle for that purpose. 

In others constructed of India-rubber the dilatation is effected by the 
insufflation of air into their cavities. 

Catheterism of the Uterus. — Sometimes, from the narrowing or 
closure of the os uteri, catheterism becomes necessary, and may be 
effected with bougies made of metal, India-rubber, or waxed cloth; 
they should be of different sizes, and their introduction into the os 
effected with the greatest gentleness. The smallest size should be used 
at first, and permitted to remain two or three hours each time for a 
few days until the parts become accustomed to the presence of the 
instrument, after which other sizes are employed until the requisite 
amount of dilatation is effected. Special dilators have also been in- 
vented for the same purpose. 

Catheterism of the Urethra. — Catheterism of the urethra is 
40 



626 CATHETEEISM. 

required to be performed in retention of urine from various causes — 
contraction of the voluntary or involuntary muscular fibres surround- 
ing the urethra, paralysis of the bladder, stricture, etc. 

In many cases other measures will often succeed in relieving the 
bladder, such as the immersion of the patient in a warm bath, the in- 
halation of the anaesthetics, the administration of a full dose of mor- 
phia or other narcotic, or an injection containing opium or camphor ; 
sometimes the evacuation of the rectum by a large enema, or the free 
use of alkaline draughts will accomplish the same object : tincture of 
the muriate of iron in ten-drop doses every ten minutes is an empirical 
remedy occasionally had recourse to. 

Catheteeism of the Male Urethea. — The instruments used in 
this operation are cylindrical tubes made of silver, waxed cloth or 
India-rubber of different sizes and forms. The scale of sizes adopted 
by some of the instrument makers is shown in Fig. 585. 

Fig. 585. 

,23U S 6 7 S 9 

ooooo O O OO 

Diagram showing the sizes of catheters. 

The catheter should be curved at its extremity to some extent, 
although a perfectly straight instrument may be made to pass into the 
bladder. The form seen in Fig. 586 is, perhaps, the best : in this the 
axis of the beak makes with that of the shaft an angle little less than 

Fig. 586. 




Catheter showing the proper curve. 

a right angle ; its point is well rounded, and pierced a short distance 
above with two oval holes or " eyes" at different heights ; to the open 
extremity of the tube two little rings are soldered for the purpose of 
attaching a retentive bandage if required ; and also to serve as an 
indication of the position of the point of the instrument. 

Method of Introduction. — The patient may stand in front of the sur- 
geon, while the latter sits in a chair, or he may lean with his back 
against a wall, or again, he may sit upon the edge of the bed, with his 
knees widely separated, and the feet supported on a stool ; though the 
most convenient position both for the surgeon and patient is for the 
latter to assume a horizontal posture, with his shoulders slightly ele- 
vated, the thighs drawn up, and the knees wide apart. The surgeon 
having warmed, and well oiled the catheter, which he holds lightly be- 
tween the thumb and index and middle fingers of the right hand, 



CATHETERISM OF THE MALE URETHRA. 627 

stations himself upon the patient's left side, as the most convenient in 
operating ; he then takes the head of the penis between the fingers of 
the left hand, makes pressure upon it to open the meatus, into which 
the poiot of the instrument, with its concavity placed across the left 
groin, is introduced, and pressed along the urethra, taking care to 

Fig. 5S7. 



Mode of introducing the catheter. 

keep the point in contact with its upper wall until it reaches the arch 
of the pubis, when the shaft of the instrument should be carried to 
the median line of the abdomen, and then depressed between the thighs, 
which movement will throw the point of the catheter into the bladder. 

In this manner, with a little practice, the catheter can be introduced 
with neatness and rapidity. 

Should this method fail, there is another plan, called by French 
surgeons the " tour de maitre," which will sometimes succeed ; it is 
executed in the following manner : The patient may either assume 
the erect posture or lie down ; the surgeon stands upon his right side, 
and passes the catheter with its open extremity looking downwards, 
into the urethra down to the triangular ligament ; then by a lateral 
sweep through a semicircle he brings the shaft of the instrument to 
the median line of the abdomen; it is now depressed towards the 
thighs, to raise the point of the catheter into the bladder. 

In either case, it will be known that the instrument has entered the 
bladder by the ceasing of the resistance to its progress, by the flow 
of urine, and by its beak rotating freely in the bladder when the 
shaft is rolled between the fingers. 

If the silver catheter does not pass, a gum catheter may be tried, 
having impressed upon it the curve deemed by the surgeon most 
likely to insure its successful introduction. The wire stylet may be 



628 



CATHETEEISM. 




partially withdrawn from the catheter in those cases where the pros- 
tate gland is enlarged, so that its point may rise above the obstruction 
and enter the bladder. 

It will be always advisable in a healthy urethra to use a large 
instrument (No. 7 or 8, for instance), as it fills the canal fully, and is, 
therefore, less apt to catch in the folds of the mucous membrane. 
Should its point meet with any obstruction, the instrument may be 
slightly withdrawn, then again shoved forwards ; or the penis may be 
stretched by drawing it along the shaft of the catheter, which will 
sometimes overcome the difficulty. 

In old people the middle lobe of the prostate is often so hyper- 

trophied as almost to close the 
Fig. 588. urethra, as seen in Fig. 588. 

The open extremity of the 
catheter in such a case as this 
must be depressed more than 
would be required in operat- 
ing upon a healthy urethra, so 
that the point of the instru- 
ment may pass above the ob- 
struction ; or perhaps a much 
more effectual plan will be to 
introduce into the rectum the 
left forefinger, with which the 
point of the instrument may 
be pressed upwards. 

The instrument should be 
longer than the one commonly employed, as the urethra is stretched 
by the enlarged prostate, and its curve must also be greater. 

It should always be borne in mind in all cases offering obstruction 
to the free ingress of the catheter, that gentle and patient manipulation 
will accomplish much more securely, and certainly the object in view, 
than any forcible efforts, which are liable to lacerate the urethra and 
produce false passages ; and when these occur in the membranous and 
prostatic portions of that canal, fatal suppuration 
may be engendered. If the catheter is to be re- 
tained in the bladder, it may be fastened with 
four threads to a ring prepared of metal or any 
convenient material, and large enough to encircle 
the penis in a state of erection so that no con- 
striction can possibly happen ; the ring is shoved 
up to the root of the penis and held in that 
position by threads or tapes passing upward and 
under the perineum to a belt around the waist. 

M. Yelpeau sought to secure the same object 
with the arrangement seen in Fig. 589. A piece 
of linen is wrapped around the penis posterior 
to the glands, and four threads attached to the 
rings of the catheter are then wound about the 

Yelpeau's method of fasten- n d [d ^ , j gQ , ^ 

ing a catheter. -t <-> 



Hypertrophy of the middle lobe of the prostate gland. 



Fig. 589. 




CATHETERISM OF THE FEMALE URETHRA. 



629 



previous one. inasmuch as it may produce constriction of the organ 
in case of erection. 

Catheter ism of the Female Urethra. — The female catheter is a silver 
tube seven or eight inches long, and slightly covered at its extremity. 
It may be introduced in the following manner : One hand is carried 
beneath the bedclothes, and the tip of the index finger • seeks the ori- 
fice of the urethra below the junction of the nymphae, which may be 
known by an impression communicated to the finger resembling 
somewhat that received by pressing it upon the end of the barrel of 
a key; then the catheter held in the other hand is conducted upon 
the index finger into the urethra. 

Another simple plan is to use one hand only, holding the catheter 
between the thumb and index finger in the manner seen in Fisr. 590. 
The tip of the instrument 



rests beneath the point of 
the index finger which feels 
for the meatus, and, when 
found, the instrument may 
be easily slipped into it. It 
is simply necessary to hint, 
that no exposure of the pa- 
tient's person is required in 
these manipulations. 

In pregnant women, the 



Fig. 590. 




Method of holding the female catheter. 



Fig. 591. 




Retentive bandage for the female catheter. 



uterus, in its development, draws up the urethra some distance, so 
that the meatus must be sought a little higher up than usual, behind 
the lower margin of the arch of the pubis; in such cases, the male 
catheter will, very often, be found the most convenient instrument. 



630 REMOVAL OF FOREIGN BODIES. 

During the descent of the head of the child ; the female urethra 
may be compressed, in which instance a flat catheter will answer 
better than one of a cylindrical form. 

The neatest retentive bandage for the female catheter is arranged 
by attaching two threads to the rings of the instrument, and passing 
them around the upper part of the thighs, in which position they are 
sustained by two pieces of bandage extending from the centre of a belt 
around the waist to either thread, both in front and behind (Fig. 591). 



CHAPTER XIV. 

KEMOYAL OF FOREIGN BODIES. 

The removal of foreign bodies from the various parts of the body 
demands attentive consideration, as most cases of this kind are sudden 
emergencies, and call for prompt treatment, both to avoid the morbid 
conditions that their continual presence may occasion, and to calm 
the apprehension of the patient, which is usually considerable, even 
in the least serious cases. In certain instances the life of a person 
may be immediately involved by the presence of an extraneous body 
in the natural cavities. 

Foreign Bodies in the Skin. — The most common objects that 
penetrate the skin are pins, needles, splinters of wood, fragments of 
stone, iron, or glass, and grains of gunpowder. The removal of rifle 
balls, fragments of shell, and pieces of clothing, comes naturally under 
the subject of gunshot wounds, and will therefore be considered under 
that head. 

The hands of washerwomen and seamstresses, and the knees of 
children, are most frequently penetrated by pins and needles, which 
may be either partially or wholly buried beneath the skin. In the 
former case, they may easily be seized with the forceps and extracted ; 
this cannot often be effected in the latter instance, for the object may 
be entirely concealed from the most scrutinizing examination, or at 
least can only be felt and moved beneath the skin with the fingers. 
Needles have remained imbedded in the tissues for years without 
causing the slightest trouble ; in other instances they have produced 
soreness and stiffness of the muscles, and suppuration. 

When the object can be felt, it should be removed by steadying it 
with the fingers, and making an incision down upon it, when, with 
the forceps, it may easily be seized and extracted. Exploratory 
incisions should never be made, as it can rarely happen that the 
body will be found. Mr. Erichsen recommends, for the purpose of 
extracting needles, thorns, splinters of wood, and other foreign bodies 
of small size and pointed shape, lying in narrow wounds, the forceps 
shown in Fig. 592. They have very fine, but strong and well-serrated 
points. 



REMOVAL OF FOREIGN BODIES 



631. 



Sometimes a needle penetrates the knee-joint of 
children while romping upon the floor ; and in two 
cases of the kind which have come under my notice, 
the inflammation excited by it resulted in anchy- 
losis. The joint should be kept quiet for a few da}^s, 
and recourse had to cold water-dressings, or other anti- 
phlogistics, should inflammation arise. If the needle 
can be felt, it may be pressed as near the surface as 
possible, and removed through a valvular incision. 

Workmen in wood often run splinters into the 



Fig. 592. 



Erichsen's forceps for 
removing foreign bo- 
dies from the skin. 



skiu, or what is yet more painful, under the nail. 
They may be removed with the point of a needle or a 
bistoury, pressed beneath their projecting extremity, 
to lift them from their bed. Softened with the mois- 
ture of the parts in which they stick, splinters some- 
times break in two, and leave no projecting end to be 
seized by the forceps ; in such a case it will be neces- 
sary to run the point of a bistoury the whole length 
of the splinter, and then dislodge it with the forceps. 

A large splinter, run beneath the nail, causes severe pain ; and if 
it cannot be extracted with the forceps, the nail should be split up in 
the direction of the foreign body. 

In blasting rock, fragments of stone may be driven into the tissues; 
the general rule in such cases is, to remove the objects immediately, 
if they can be felt, through an incision made upon them. 

Grains of gunpowder, in explosions, sometimes stick into the skin 
of the face and hands. When the grains are not numerous, they may 
be taken out with the point of a needle ; but in the majority of cases, 
neither the surgeon will feel inclined to undertake, nor the patient dis- 
posed to undergo, such a tedious operation. It has been recommended 
to apply a blister to the part for three or four hours, then to remove it 
and substitute a poultice ; a more successful and agreeable plan, how- 
ever, is to lay over the discolored surface, with a camel's-hair brush, a 
solution of corrosive sublimate in glycerine (gr. ij to fjj). This solu- 
tion does not dissolve the powder, but causes the little pits in which 
the grains are imbedded to suppurate and discharge them. 

Gold and silver rings may constrict the fingers and require removal ; 
if there is not much tumefaction it may be accomplished with a fine 
file ; they may also be worked off if a piece of tape can be gotten 
beneath them, but the most ingenious plan is to convert them into an 
alloy with mercury, when they can be easily crushed beneath the 
fingers. 

A case came under my notice where a boy having been punished 
for wetting his bed, and feeling his inability to prevent a recurrence 
of the involuntary discharge, tied a string about the penis. Inflam- 
mation and swelling succeeded ; so as to hide it from view, and urina- 
tion became impossible; the boy would give no information concerning 
the matter until the severe pain which it caused compelled him to 
divulge the secret. 



632 REMOVAL OF FOREIGN BODIES. 

The cord was snipped with the scissors, and all the bad symptoms 
disappeared. 

Foreign Bodies in the Eye. — The surgeon has more frequently 
to deal with foreign bodies in the eye than in any of the other organs. 
They cause severe pain, intolerance of light, and a profuse secretion 
of tears ; the conjunctiva becomes congested, and not uncommonly its 
enlarged vessels cause the patient to experience a sensation as if the 
foreign body was still in the eye, after its removal. 

Cinders, spicules of iron, of steel, or stone, and sand, are the foreign 
objects that most often gain admission into the eye. When they 
simply repose upon the conjunctiva, the constant winking and flow of 
tears which they produce, with the rubbing which the patient usually 
inflicts upon the organ, not unfrequently carry away the offending 
cause. Should this not occur, the eye may be exposed to a good light, 
and while he holds the lids apart, the operator may remove the object 
with the point of a camel's-hair brush, the corner of a pocket hand- 
kerchief, the eye of a needle, or the bulbous extremity of a probe. 
To explore the inner surfaces of the eyelids they should be everted ; 
the upper one, by drawing out the lid with the forefinger and thumb 
of the left hand, while pressure is made upon its upper surface with 
the pulp of the right index finger, or preferably the point of a probe 
or lead pencil ; the lower lid is easily exposed by simply drawing it 
down upon the cheek. 

The most difficult objects to remove are little bits of iron or steel 
when they become imbedded in the conjunctiva; the greatest gentle- 
ness and patience should be exercised in these cases lest irreparable 
injury be done to the structure of the eye. 

The best plan is, after securing the benefit of a good light, to place 
the point of a cataract-needle (or a common one will do very well) 
beneath the bit of metal and lift it from its bed. After the removal 
of the intruder, cold water applications will be found both agreeable 
to the sensations of the patient and beneficial in checking inflamma- 
tory action. A drop of glycerine placed between the lids will also 
produce an agreeable sensation of relief. 

Foreign Bodies in the Ear. — Beans, peas, beads, small pebbles, 
insects, particularly the earwig, and similar bodies sometimes gain ad- 
mission into the external meatus either accidentally or intentionally. 
They occasionally produce intense pain, especially those that, being 
absorbent and swelling, distend the auditory canal. The cerumen 
may also collect in hard pellets and occasion deafness, singing in the 
ears, and dizziness. 

In children, the irritation from a foreign body in the ear may be so 
great as to produce convulsions. 

The ear in these cases should be carefully examined by placing the 
patient's head in such a position that the rays of a strong light may be 
concentrated in the meatus, which should be straightened as much as 
possible by drawing the auricle upwards and backwards. Or a 
speculum may be used, that of Mr. Toynbee, of Dublin, is the 
best (Fig. 593). Wilde's instrument, seen in Fig. 594, sometimes 



FOREIGN BODIES IN THE EAR. 



633 



employed, is conical in shape and causes a good deal of pain when 
the lining membrane of the meatus is much swollen and tender. I 
have been in the habit, for several 



Fig. 593. 



Fig. 594. 



years, of using the illuminating 
otoscope, seen in Fig. 595, which I 
prefer to all others ; for with a lit- 
tle practice, the meatus and mem- 
brane of the tympanum may both 
be beautifully illuminated, and I 
have succeeded in discovering a 
foreign body, in this manner, when 
other instruments have failed me. 
In using the otoscope, the tube is 
introduced into the meatus with the 
funnel, b, of the instrument look- 
ing backwards ; in front of the lat- 
ter a steady flame is put so that the 

rays of light may strike upon the polished metal mirror, c, which 
throws the rays in the direction of d e, into the meatus ; the eye of the 

Fig. 595. 





Toynbee's ear speculum. Wilde's ear speculum- 




Otoscope. 

observer placed at a can now see the membrane of the tympanum 
illuminated through the tube a d e, which is movable, to enable the 
surgeon to adjust the focus of a convex lens located at e. 

The simplest and at the same time most efficient way of dislodging 
an extraneous object in the meatus is by throwing a stream of water 
into it in the manner described at page 108. 

Fig. 596. 



T~-^i 



Instrument for removing foreign bodies from tbe ear. 

Should this not succeed, an eyed probe may be bent a little at its 
extremity, and used as a hook to draw the body forwards ; a curette 
will sometimes answer the same purpose (Fig. 596). 

Mr. Toynbee recommends a pair of rectangular forceps, which will 
enable the surgeon to look into the auditory canal while the instru- 
ment is being used in seizing the object (Fig. 597). 



634: 



REMOVAL OF FOREIGN BODIES. 
Fig. 597. 




Toynbee's forceps for removing foreign bodies from the meatus. 

Dr. Hewson, of Philadelphia, has constructed a pair of forceps bent 
at their articulation; the blades are separable from each other, and 

form at their extremities little 
Fi &- 598 - oval rings, which are well adapt- 

ed for seizing hold of rounded 
objects; a single blade may be 
used, if necessary, as a lever. 

Dr. Corse, of the same city, 
devised for this purpose the in- 
strument represented in the an- 
nexed wood-cut (Fig. 599), and 
Hewson's forceps. described by him in the Ameri- 

can Journal of the Medical Sci- 
ences for October, 1858. It consists of two equal sections of a cylinder, 
rounded at one end, and fenestrated at the other ; these are connected 

Fig. 599. 




Corse's instrument for removing foreign bodies from the ear. 

together by a small piece of metal bearing two little pins upon either 
side, which slide into the fenestra. By this arrangement, the blades 
can be introduced into the meatus singly, and then united by the pins. 

The canula-forceps may also be used for seizing small bodies, but 
they are not nearly so efficient or manageable as the foregoing instru- 
ments. 

Insects may be suffocated by filling the meatus with sweet oil or 
glycerine, and then washed out with the syringe. 

Concreted cerumen, as stated above, sometimes causes deafness and 
irritation of the auditory canal : the plan to follow in this case is first 
to soften the wax with a solution of the carbonate of soda in water 
(gr. x to f 3J), and then to wash it out with warm water or to scoop it 
out with a curette. 

Should the removal of any of the foreign bodies be likely to cause 
much suffering to the patient, the administration of chloroform will 
be requisite. 

The after-treatment will consist in combating local inflammation by 
the application of leeches first, and then emollient dressings. 



FOREIGN BODIES IN PHARYNX AND (ESOPHAGUS. 635 



Fig. 600. 



Fig. 601. 



Foreign Bodies in the Nose. — Buttons, beans, or beads are some- 
times thrust into the nose by children in their play ; they often cause 
considerable irritation and inflammation of the mucous membrane, 
which swells up, and closes the nares so as to give a good deal of 
trouble in removing them. 

The eye-probe, bent at its point, may be used as a hook to draw 
out the intruder, or a canula with a wire loop running through it. 

Sometimes the injection of water, either from before backwards or 
the reverse, will succeed ; in the former case the object will of course 
be carried into the pharynx, from which it can readily be expelled by 
the voluntary efforts of the patient. 

Causing the patient to sneeze violently by snuff or other sternu- 
tatories, while the mouth is held shut, may also dislodge the foreign 
body. 

Foreign Bodies in the Pharynx and (Esophagus. — Small ob- 
jects, such as bristles, needles, pins, buttons, coins, fragments of fish 
or chicken bone, sometimes lodge about the base of the tongue, in the 
lower part of the pharynx or oesophagus, causing an uneasy sensation 
in the throat and a constant disposition to hawk and cough. Should 
the body be larger, and become impacted behind the larynx, as occurs 
from a morsel of meat beings arrested 
at this point of the oesophagus, the 
most distressing symptoms of suffo- 
cation are produced, and death may 
result from suffocation. 

Prompt action is required in the 
treatment of these cases; the sur- 
geon should first throw the patient's 
head back, and pass his index fin- 
ger into the pharynx ; he may suc- 
ceed in this manner either in fishing 
out the object, or shoving it beyond 
the larynx if suffocation is threat- 
ened; though it will be better, should 
delay be possible, and the object 
indigestible, irregular in shape, or 
likely to injure the mucous mem- 
brane of the stomach, to remove it 
with a pair of forceps. Those most 
likely to be at hand will be the 
dressing forceps, which will answer 
very well if the object is not too far 
down; the best instruments, however, 
for the purpose are the forceps seen 
in Figs. 600 and 601, devised by Dr. 
Bond, of Philadelphia; in one pair 
the blades are curved at right angles 
with the rivet, and in the other in 
the same plane with it; their inner margins are bevelled outwards, 
leaving a line of serration only at their centres ; an arrangement that 




Bond's gullet forceps. 



636 



REMOVAL OF FOREIGN BODIES, 



will prevent the mucous membrane of the gullet being pinched between 
them when the forceps are closed. 

In using this instrument the head of the patient is thrown back, and 
the blades of the forceps glided over the tongue into the oesophagus, 
as seen in Fig. 602. 

It may be observed that the constant motion of the tongue will 
sometimes render these manipulations about the throat troublesome ; 



Fig. 602. 



Fig. 603. 





Mode of introducing the forceps into the gullet. 



Bond's gullet hook. 



this may be obviated in a great measure by letting the patient inhale 
a few whiffs of chloroform. 

If the finger should not be long enough to shove the object beyond 
the larynx, a probang will enable the surgeon to accomplish this, and 
if necessary press it also into the stomach. 

Dr. Bond contrived a hook made of copper wire silvered, or silver 
wire, of the shape presented in Fig. 603, for the purpose of removing 
pins or coins ; it is to be passed into the oesophagus beyond the object, 
and then drawn up to catch it in the hook. 

A useful instrument for the removal of needles, bristles, and similar 
objects, is shown in Fig. 604 ; it is composed of a metallic stem and 
sheath mounted with bristles, connected with them in such a manner 
that by moving the stem the bristles are made to expand laterally, 
and fill up the oesophagus; and when the instrument is withdrawn it 
sweeps, so to speak, the whole length of that canal. 

Prof. Gross recommends an excellent instrument for extracting 
foreign bodies from the gullet. It consists, as seen in Fig. 605, of a 
metallic tube fifteen inches long, and slightly curved ; through this 
runs a slender rod, bearing at its extremity four little wing-like 



FOREIGN BODIES FROM LARYNX AND TRACHEA. 637 



Fig. 604. 



Fig. 605. 



apparatus, which may be open or 
shut at pleasure by turning the 
handle of the instrument. 

Dr. Bright, of Kentucky, had 
recourse to an ingenious expe- 
dient for removing a fish-hook 
attached to a cord, that had been 
swallowed. He perforated a lea- 
den ball with a hole; through 
this he passed the string con- 
nected with the hook, against 
which the ball was pressed. In 
this manner the point of the 
hook was guarded, while the sur- 
geon took hold of the cord and 
withdrew the ball and hook to- 
gether safely. 

An emetic of mustard or the 
sulphate of zinc will often suc- 
ceed in dislodging the extrane- 
ous object from the gullet ; it 
should be assisted by drinking 
freely of water or some demul- 
cent fluid. 

Foreign bodies that have en- 
tered the oesophagus may remain 
in that canal without causing 
any trouble for a long time, or 
they may escape into the blood- 
vessels, or other organs of the 
thoracic cavity, and produce fatal 
hemorrhage, or inflammation 
and suppuration. In other cases 
the object slips into the stomach, 
remains there for a longer or 
shorter time, and is finally voided 
by stool ; or the intestines may 
be perforated, and the object ulti- 
mately emerge from the skin. 

The after-treatment requires 
the use of emollient fluids, if the foreign bodies produce irritation of 
the oesophageal or gastric mucous membrane. 

Eemoval of Foreign Bodies from the Larynx and Trachea. 
— From carelessness in holding small objects in the mouth, they are 
sometimes accidentally drawn into the larynx and trachea during the 
inspiratory act, giving rise to a most distressing condition, which calls 
often for immediate surgical interference to save life. 

The articles that commonly intrude themselves in this manner are 
coins ; seeds of certain fruits, as the cherry and plum ; grains of corn 




Instrument for removing 
needles from gullet. 



Gross's instru- 
ment for removing 
foreign bodies from 
the oesophagus. 



638 EEMOVAL OF FOKEIGN" BODIES. 

and coffee ; beans ; bits of meat ; buttons ; pebbles ; cockle-burs ; teeth in 
several recorded cases ; and a number of other substances. According 
to their size, shape, weight, and the condition of their surface as to 
smoothness, they occupy different portions of the air-passages: those 
that are light, sharp-pointed, or covered with projecting points, may 
stick at the superior orifice of the larynx, or catch when they arrive 
at its ventricles; while those that are round, heavy, and smooth, 
will generally glide through the larynx and trachea, and lodge in the 
bronchi ; the right one, from its size and position, being most frequently 
penetrated. The object may be fixed at any point, or move up and 
down through the whole length of the larynx and trachea. 

The results which most commonly follow from the retention of a 
foreign substance m the air-passages are inflammation of the mucous 
membrane lining them ; pneumonia of a portion or the entire of one 
lung, corresponding with the bronchi in which the body is located ; 
phthisis ; pulmonary emphysema ; and lastly emaciation. 

The symptoms produced are those characteristic of obstructed 
respiration ; the patient coughs violently, gasps for breath, seizes his 
throat as if to tear away some obstruction there ; stares about him 
wildly; and not unfrequently falls down unconscious. The face 
becomes livid and swollen ; and there is more or less expectoration 
of mucous matter, occasionally accompanied with blood, during the 
fits of coughing. This paroxysm lasts from a few seconds to several 
minutes, or even longer, when the breathing becomes more tranquil 
and the severity of the symptoms diminish. Thus the patient will be 
harassed with alternate paroxysms of these distressing symptoms and 
periods of abatement, until he either dies suffocated, or worn out by 
consecutive disease of the thoracic viscera. Cases have been observed 
in which none of the above phenomena were present, or, if so, in a 
very mild degree. 

The cough is at times of a spasmodic character, resembling that of 
croup, so as to render the diagnosis of the case difficult ; other of the 
symptoms have also been so simulated by those of catarrh, pneumonia, 
and phthisis, as to embarrass the judgment of the practitioner. 

An accurate inquiry into the history of the case, with a careful 
physical examination of the chest, is the only means of arriving at 
a correct conclusion in such instances. 

When the diagnosis has been clearly made out, an effort should be 
made by the surgeon to dislodge the foreign body from the air- 
passages by placing the patient in such a position that the head and 
chest may be lower than the rest of the body, when the back should 
be struck with quick blows with the hand ; in this manner the foreign 
substance may be started, so that it will escape through the glottis, as 
was successfully done in the well-known case of the English engineer, 
Brunei, recorded by Sir B. Brodie ; a half sovereign had accidentally 
slipped into this gentleman's trachea while amusing some children. 

The foreign body will in some cases be expelled by violent efforts 
at coughing. 

Should this process fail, nothing remains but to perform the opera- 



FOREIGN BODIES FROM URETHRA AND BLADDER. 639 



tion of laryngotomy or tracheotomy, and to extract the foreign body 
with properly constructed forceps. 

After the patient has been relieved from the presence of the object 
in the windpipe, he is not always secure of his life, inasmuch as the 
inflammatory condition of the mucous membrane of the air-passages 
and lungs excited by it, may lead to a fatal termination. These com- 
plications should engage the earnest attention of the medical attendant, 
that they may be combated by appropriate measures. 

Kemoval of Foreign Bodies from the Urethra axd Bladder. 
—The urethra may become obstructed by the presence in it of frag- 
ments of calculi, clots of blood, concrete mucus, or fragments of 
bougies which have broken off the instrument during its introduction. 
In other cases, persons have designedly put into the canal sticks, slate- 
pencils, or hair-pins. They may occupy any portion of the urethra ; 
and give rise to retention, local inflammation, and pain. 

"When near the orifice, their removal may be effected by seizing them 
in the jaws of a pair of finely-pointed forceps (Fig. 611), or with a bent 
probe, curette, or a loop of fine wire. If further in, they may occasion- 
ally be pressed towards the meatus, 
and removed in the manner above 
mentioned ; or, if this cannot be done, 
perhaps a large-sized catheter intro- 
duced down to the obstruction, so 
as to dilate the urethra and permit 
the foreign body to move forwards 
by the pressure of the urine behind, 
may succeed. 

Mr. Weiss, of London, has in- 
vented an instrument for dilating 
the urethra, shown in the annexed 
wood-cut (Fig. 606); it consists sim- 
ply of a metallic stem divided into 
two equal segments, and capable of 
being expanded to the required ex- 
tent, so that the points of the forceps 
may be introduced. 

Many ingenious urethral forceps 
have been devised for the purpose of seizing hold of the intruding 
substance and removing it. Fig. 607 shows an instrument composed 



Fig. 606. 




Weiss's urethral dilator. 



Fig. 607. 




Urethral forceps. 



of three slender branches, which are inclosed in a canula, and when 
brought down to the object, may be protruded to grapple it. 

Weiss's forceps consist, as seen in Fig. 608, of two blades, B, inclosed 



64:0 



REMOVAL OF FOREIGN BODIES 



in the canula A, for seizing the fragment of calculus, while it may be 
reduced to powder by the drill working between them. 

Fig. 608. 




Weiss' s forceps. 



A convenient instrument will be found in the scoop-pointed canula 
with a narrow tongue moved by a central stem, as seen in Fig. 609, 



Fig. 609. 




Instrument for removing foreign bodies from the urethra. 

or the double-bladed forceps delineated in Fig. 610, which consists of 
two narrow blades concealed in the canula (a), and capable of being 
expanded by being thrust forwards, and, when the foreign substance 

Fig. 610. 




Double-bladed urethral forceps. 

is grappled, closed again by simply shoving the canula upon them ; 
the screw D regulates the distance between the blades. 

In manipulating with these instruments, the finger should be placed 
upon the foreign body, to prevent its moving while it is being seized. 

Should the surgeon fail with the forceps, nothing remains but to 

Fig. 611. 




Urethral forceps. 



cut down upon the urethra and remove the obstructing substance; 
and, if it is possible, this should be pressed into the membranous 



REMOVAL OF FOREIGN BODIES FROM THE RECTUM. 641 

portion of the canal, and the incision made upon the perineum, for 
the reason that wounds of the membranous urethra heal with much 
greater celerity and certainty than those anterior to the bulb. 

The female urethra is short and very dilatable, and little difficulty 
will therefore be encountered in removing extraneous substances from 
it; for this purpose the delicate pair of forceps seen in Fig. 611 will 
answer very well. 

Eemoval of Foreign Bodies from the Vagina. — Large objects 
may be introduced into the vagina, either by the patient herself, under 
some unnatural excitement, or, criminally, by another person ; or cer- 
tain instruments, such as pessaries, that have been employed in the 
treatment of uterine disease, are permitted to remain in the canal until 
they produce great derangements of health, and, in some cases, ulcera- 
tion into the rectum or bladder. M. Cloquet reports a case in which 
a cork pessary remained in the vagina ten years. 

For the removal of these objects, great delicacy of manipulation is 
required. The vagina should be first syringed, to clear away all ad- 
hering mucosities; a speculum is then introduced, and its walls dilated ; 
when the object is thus brought into view, it may be seized with the 
forceps and withdrawn. If the body is large and impacted, it may 
become necessary to divide the sphincter. 

Removal of Foreign Bodies from the Rectum. — Foreign sub- 
stances are sometimes introduced into the rectum by design, such as 
pebbles, pieces of wood, vials, and bougies ; or they are ingested, and 
become entangled in the folds of mucous membrane just within the 
sphincter ; of these the most frequent are the seeds of fruits, such as 
cherries, grapes, &c. In old people, especially females, the feces become 
impacted in the rectum, even in some cases as high as the sigmoid 
flexure, giving rise to derangements of digestion, loss of sleep, pain 
and a sensation of fulness in the bowel; the patient passes a thin mu- 
coid fluid, often tinged with blood, so as to lead the medical attendant 
to suspect the presence of dysentery. 

The removal of the feces is effected by breaking down the hard- 
ened mass with the finger, well oiled, and passed into the gut; should 
this not be long enough to reach, the handle of a tablespoon may be 
used, or the ordinary scoop employed in lithotomy (Fig. 612) to clear 

Fig. 612. 



Scoop for removing foreign bodies from the rectum. 

the bladder of the ddbris of calculi. A copious stream of warm water 
must also be thrown into the bowel, with the India-rubber ball 
syringe attached to a long muzzle, or the tube of the stomach-pump, 
to soften the feces, which will render the operation less painful. 
When small objects are present, they may be seized with the forceps 
and withdrawn; and larger ones may be crushed with a strong in- 
strument and removed piecemeal, as was done by Dr. Parker, of 
41 



642 ON THE MODES OF ARRESTING HEMORRHAGE. 

Canton, in the case of a Chinaman, into whose rectum a glass goblet 
had been thrust. 

In the case recorded by Marcetti, of a courtesan who had the butt- 
end of a pig's tail, rendered rough by having its bristles cut off, 
forced into her rectum by some students, the removal was accom- 
plished by slipping a piece of reed over the pig's tail, to which a cord 
was attached, so as to protect the rectal mucous membrane. In the 
same manner any rough object may be extracted through a large 
metallic tube. 



CHAPTER XV. 

ON THE MODES OF ARRESTING HEMORRHAGE. 

Hemorrhage, whether proceeding from accidental wounds or from 
those following the employment of the surgeon's knife — or whether it 
rushes in angry torrents from any part of the body in consequence of 
disease, is always a serious misfortune, and often involves the safety 
of the patient's life by its quantity or continuance. 

In that variety of hemorrhage arising from the first two causes, 
which principally concerns us here, the blood may issue from the 
capillaries, veins, or arteries. 

Capillary hemorrhage rarely takes place to any considerable extent 
unless it be in those persons laboring under the hemorrhagic dia- 
thesis, or in whom the blood has undergone morbid changes, and the 
constitutional powers are broken down by great fatigue, improper or 
insufficient food, or other causes. 

Venous hemorrhage, when from small vessels, usually quickly 
ceases by the collapse of their walls ; if the veins are larger, or so 
connected with the surrounding tissues that their walls cannot fall 
together, the hemorrhage will take place freely ; the blood, which is 
of a dark color, runs from the wound in a continuous stream, and is 
increased in quantity by a ligature placed around the limb above the 
part injured ; the lower extremity of the vein always supplying the 
blood, except in a few cases where the vessel is too large to be 
closed completely by the valves with which it is provided; in this 
case the blood will flow from both ends of the vein. 

Arterial hemorrhage, as its name implies, springs from the arteries, 
and is the variety which the surgeon is most frequently called upon 
to control. The vessels may be partially or completely divided, or 
the wound may be transverse or longitudinal to their axis. The blood 
escapes per saltum, as it is designated — that is, in jets isochronous 
with the contractions of the heart ; and it is florid, and more or less 
frothy. Pressure in the course of the vessel above the wound, 
diminishes or arrests it. In deep or sinuous wounds the blood may 
simply well up, instead of escaping per saltum, as it usually does, in 



ON THE MODES OF ARRESTING HEMORRHAGE. 643 

consequence of its force being broken by striking against their walls ; 
but the red color remains, to distinguish it from venous blood. 

In wounds of the large arteries of the limbs, the condition of the 
circulation in the latter will depend upon the point at which the 
injury is inflicted. If the trunk is cut through high up, above the 
large anastomotic branches, pulsation cannot be felt in the vessels 
below; while, on the other hand, if these branches are above the 
wound, this pulsation will be only diminished. In the former case, 
the upper extremity of the artery alone pours out blood ; and in the 
latter, both extremities bleed. The blood usually escapes from the 
lower orifice in a continuous stream, as in the veins ; but if the circu- 
lation is rapid, and the anastomosis undisturbed, the stream may leap 
forth per saltum. 

When an artery of large size is cut in two, the blood gushes out 
rapidly, and, if not instantly checked, the patient dies in a few 
seconds. The hemorrhage from smaller arteries is less copious, and 
after a certain quantity has escaped, the patient faints, and thereby 
the force of the circulation is diminished ; the ends of the severed 
artery retreat amidst the surrounding cellular tissue; and they also 
contract so as to bring the margins of the divided inner coats in con- 
tact, and diminishing the canal immediately above. The blood in the 
vessel coagulates as high up as the first collateral branch above, form- 
ing a sort of internal plug, while an effusion of plastic matter at the 
orifice of the vessel serves the purpose of an external plug. By 
the combined action of these conditions, the hemorrhage is naturally 
arrested, and no more bleeding occurs in some cases ; in other instances 
as soon as reaction is established, the hemorrhage is renewed in con- 
sequence of the increased force of the circulation forcing the clots 
from the mouth of the artery. This may occur again and again 
until the vessel is tied or the patient dies exhausted. This is called 
intermediary hemorrhage. Should the vessel be partially divided — 
say a quarter of its circumference — the blood will escape per saltum, 
but not so freely as in the former case, because a part of it keeps on 
in its natural course. In this case, if pressure is made over the in- 
jured part, the wound in the artery may heal up. If half or three- 
fourths of the circumference be divided, no contraction of the wounded 
artery can take place, unless the tongue of tissue remaining is de- 
stroyed by ulceration or the knife ; and the bleeding will necessarily 
continue indefinitely. Hence it is that wounds of arteries of this 
character are more serious than those in which they are cut in two, 
and the bleeding from them is more difficult to stanch. 

When an artery is violently twisted or torn, there is usually little 
or no hemorrhage, as its internal coats are lacerated and then promptly 
retract. 

After an artery has been secured and the bleeding arrested until the 
lapse of some time, and then the hemorrhage is renewed, it is said 
to be secondary. It may occur in any sort of wound, and is most 
commonly observed between the fifth and twenty-fifth days. The 
hemorrhage depends upon several causes, among which may be men- 
tioned sudden movements of the wounded parts, or violent muscular 



644: ON THE MODES OF ARRESTING HEMORRHAGE. 

exertion ; ulceration of the artery ; sloughing ; the hemorrhagic dia- 
thesis, a peculiar condition sometimes observed to be hereditary ; or by 
perforation of the vessel by a spicula of bone. In one case it resulted 
from the excitement of coitus. As in primary hemorrhage, both ends 
of the artery should also be tied in secondary hemorrhage. 

The methods that have been suggested from time to time for arrest- 
ing hemorrhage are quite numerous, but we shall only consider those 
that are actually employed at the present day. 

1. Styptics are of two kinds — those acting mechanically, and those 
acting chemically ; among the former are classed, scraped lint, fur, 
amadou, spider's web, and various absorbent powders, such as gum 
Arabic, &c. ; among the chemical styptics we find the various astring- 
ents — tannin, galls ; matico ; powdered alum, or a saturated solution 
of that substance; sulphates of iron, copper, and zinc; creasote in 
solution ; persulphate of iron ; nitrate of silver, and many others. 
The chemical styptics act by constringing the tissues, and promoting 
the coagulation of blood ; they can only be depended on in hemorrhage 
proceeding from the capillaries and smallest arteries. 

The powerful styptic of Pagliari is prepared in the following man- 
ner: Eight ounces of tincture of benzoin, one pound of alum, and 
ten pounds of water are boiled together for six hours in a glazed 
earthen vessel, the vaporized water being constantly replaced by hot 
water, so as not to interrupt the ebullition, and the resinous mass kept 
stirred round. The fluid is then filtered, and should be kept in 
stoppered bottles. 

The coagulative power of this fluid is remarkable, every drop of it 
poured into a glass containing human blood produces an instantaneous 
magma ; and, by increasing the proportion of the styptic to the quan- 
tity of blood, a dense, homogeneous, blackish mass results. 

M. Maisonneuve, in operations attended with much hemorrhage, 
uses the perchloride of iron applied to each vessel by a pledget of 
charpie which is allowed to attach itself to the wound. The fluid 
forms a brown eschar which separates from the wound in from twenty 
to thirty days, leaving a healthy granulating surface beneath. 

2. Cold. — In bleeding from the small vessels of the skin and 
capillaries, the simple exposure of the wound to the air suffices often 
to check it ; cold water, and evaporating solutions applied with cloths 
will be found more efficient still ; ice, powdered and inclosed in oiled 
silk or a bladder, laid over the part, is also a powerful hemostatic ; or 
a lump of ice may be put right upon the wound. The action of cold 
as a styptic is similar to that of the astringents, and cannot be relied 
upon in bleeding from large vessels. 

3. Actual Cautery acts mechanically in sealing up the orifices 
of the bloodvessels, and the hemorrhage is liable to be renewed when 
the eschars separate ; the iron should only be brought to a black heat, 
so that it may also excite the adhesive inflammation in the parts as 
well as sear them. In secondary hemorrhage from a sloughing stump, 
the actual cautery will be found a valuable resort. 

4. Pressure is often employed to check hemorrhage. Sometimes 
it is continued until the bleeding vessels are firmly sealed up, so that 



ON THE MODES OF ARRESTING HEMORRHAGE. 



645 



upon its removal the blood will not again flow ; or the pressure may- 
be a temporary expedient until other more reliable means are prac- 
tised to secure the bloodvessel. The pressure is exercised either with 
the fingers or with specially constructed instruments called tourni- 
quets and compressors. It is most efficient and certain when the artery 
can be pinched against a solid resisting surface, as bone. In this 
manner the facial, temporal, and occipital arteries can be compressed 
against the bone beneath. The flow of blood through the carotid 
may be arrested by making pressure upon it with the fingers against 
the cervical vertebras ; the artery is easily felt at the inner margin of 
the sterno-cleido-mastoid muscle, and the pressure will be efficient 
anywhere upon its course between the hyoid bone and the transverse 
process of the sixth cervical vertebra; below this last point the 
vessel is too deep to be acted upon with any certainty. It is re- 
markable, considering the anatomical relations of the carotid, how 
long pressure with the fingers can be efficiently sustained without 
inconveniencing the patient to any great extent. The subclavian 
artery may be compressed over the first rib either with the thumb or 
with the padded ring of a key placed just above the clavicle. In a 
case of a gunshot wound of this vessel, I packed the wound with 
pieces of sponge until they projected above the surface ; a compress 
was put on the sponge, and the whole dressing sustained by a tourni- 
quet passing around the shoulder and the corresponding elbow; though 
this mode of arresting hemorrhage is very uncertain. 

The axillary artery passing through the axilla may be compressed 
with the fingers against the head of the humerus. 

The brachial is comparatively superficial, and may be found run- 
ning along the inner borders of the coraco-brachialis and biceps 
muscles. It may be compressed at any part of its course against the 
humerus, as shown in Fig. 613. The 
radial and ulna arteries may be easily 
felt at the lower thirds, and the flow of 
blood arrested in them by compression 
against the bones beneath. This plan is 
sometimes pursued in wounds of the 
palmar arch, but is far from satisfac- 
tory. In one case I was called upon to 
amputate the forearm for gangrene, 
where a practitioner had applied com- 
pression to the radial and ulnar arteries 
for palmar hemorrhage. In another, 
the bleeding continued in spite of the 
most persevering compression, to such 
an extent as to jeopardize the patient's 
life. An incision was immediately made, 
and the artery ligated. If compression 
is employed at all in these cases, the 
best mode of effecting it is by stuffing 
the wound in the palm full of lint in the 
form of a graduated compress, until it Mode ofcom pre 8 si n g the brachial art, 



Fig. 613. 




U6 



ON THE MODES OF ARRESTING HEMORRHAGE, 



Fig. 614. 



projects above the surface. Place a second compress upon the back 

of the hand ; over each compress lay a small stick transversely ; then 

bind the extremities of the sticks together. 

In profuse bleeding from wounds 
of the iliac arteries, and from the 
uterus, compression may be made 
for a short time upon the abdominal 
artery. The patient should be placed 
horizontally, with his shoulders ele- 
vated, and the thighs drawn up to 
relax the abdominal muscles as much 
as possible in this position. If the 
person is moderately thin, the circu- 
lation through the vessel may be 
arrested by pressing it against the 
lumbar vertebrae. The compression 
should be brought to bear upon a 
point in the median line just above 
the umbilicus. The external iliac 
artery is also difficult to compress ; 
but it may be accomplished with the 
fingers by pressing from before 
backwards, and from within out- 
wards, directly over the linea ilio- 
pectinea. 

With the thumbs laid one upon 
the other, as seen in Fig. 614, over 

the femoral artery as it passes over the pubis, the current of blood 

through it may be at once controlled. 

Compression upon the popliteal artery is made with a tourniquet, 

in the manner seen in Fig. 615, the vessel being pressed by the pad 

Fig. 615. 




Mode of compressing the femoral artery. 




Mode of compressing the popliteal artery with a tourniquet. 

of that instrument directly against the intertrochanteric surface of 
the femur. 

The posterior and anterior tibial may be compressed in the lower 



ON THE MODES OF ARRESTING HEMORRHAGE, 



647 



parts of their courses, the former behind the inner malleolus, and the 
latter part upon the top of the foot, at the inner side of the tendon of 
the tibialis anticus. 

In making pressure with the hands we either employ the thumbs 
in the manner we have already described, or the points of the fingers 
placed close together in a row. Just that amount of force should be 
used necessary to arrest the circulation, and no more, inasmuch as 
anything in excess of this, without doing any good, only serves to 
exhaust the person making the compression. When one hand is 
tired, the other may be substituted for it, or the fingers over the 
vessel may be reinforced by those of the other hand. 

This mode of arresting hemorrhage with the fingers is had recourse 
to usually in emergencies, until other measures can be taken to check 
the blood permanently, and also in amputations at the shoulder and 
hip-joint. In operations below these joints, and where the compres- 
sion is required to be kept up with greater certainty and for a longer 
period, tourniquets and compressors are employed. A tourniquet 
may be extemporized at any moment with a cravat, piece of rope, 
strips of any sort of cloth, or a bunch of grass, or fine roots twisted 
into a cord. If required, direct pressure may be sought to bear 
upon the bleeding artery by slipping a gravel, 
lump of earth, piece of wood, or any similar Fi g- 61(5 - 

object beneath the tourniquet. 

The apparatus known under the name of 
the "Spanish windlass" (Fig. 616) is also a 
simple and efficient contrivance; it consists 
of a compress placed over the artery, and 
fixed by the body of a cravat, the ends of 
which are knotted upon the opposite side; 
beneath the knot a piece of pasteboard, or 
other material, is laid, to prevent the skin 

Fig. 617. 





Field tourniquet. 



Spanish windlass. 



being painfully pinched when the cravat is twisted by the short stick 
introduced under it. The field tourniquet, now supplied to the medi- 
cal officers of the army and navy, consists of a pad (d), supported 
upon the convexity of a sort of cradle (b) by the upright (c). To one 
side of the cradle the ordinary lac of webbing (f) is attached, while the 
other side (g) forms, with the cross-piece (e) the buckle. From the 
peculiarity of the connections of the pad, it holds its position upon the 
artery remarkably well. 



648 



ON THE MODES OF ARRESTING HEMORRHAGE. 



The form of tourniquet most commonly used in this country is that 
of J. L. Petit, seen in Fig. 618. A strong webbing lac is attached to 

a metallic frame consisting of 
Fig- 618. two parts, moving to and from 

each other by means of a screw ; 
the lac is buckled around the 
limb, and the required degree 
of constriction is effected with 
the screw. Before the apparatus 
is put on, it is important to see 
that it is in proper order, and 
that there is no chance of any 
of its parts giving way during 
the operation ; a roller or thick 
compress should be put over the 
artery beneath the band, and the 
tourniquet placed upon the op- 
posite side of the limb ; or some- 
times this arrangement may be 
conveniently reversed — that is, 
the tourniquet placed upon the 
roller over the artery. 

The point at which the in- 
Petit's tourniquet. strument must be applied will 

vary with the requirements of 
each particular case. Fig. 619 shows the brachial artery compressed 
high up towards the axilla ; Fig. 620 presents an illustration of the 




Fig. 619. 



Fig. 620. 





Tourniquet applied to the brachial artery. 



Tourniquet applied to the femoral artery. 



ON THE MODES OF ARRESTING HEMORRHAGE 



649 



Fig. 621. 



femoral compressed with the tourniquet just below Poupart's liga- 
ment. 

To avoid the objectionable feature in the foregoing apparatus — cir- 
cular constriction of the limb — Dupuytren devised a compressor which 
has but two points of bearing, upon opposite sides of the limb. It is 
composed of two curved steel strips half an inch broad, sliding upon 
each other, and permitting the arc 
to be increased or diminished at 
pleasure. Each of the strips bears 
a pad at its free extremity ; one of 
the pads is movable, the other fixed, 
though both may be bent upon the 
steel strips at any angle by means 
of a joint controlled by a thumb- 
screw. In applying the instrument, 
the larger or fixed pad is placed 
upon that side of the limb opposite 
the artery upon which the small pad 
is made to act by the screw. 

A less complicated and more con- 
venient instrument is the compressor 
of Prof. Gross, of Philadelphia, who 
thus describes its advantages and 
construction: "It possesses several 
decided advantages over the ordi- 
nary tourniquet; first, in the facility 
of its application ; secondly, in the 
amount of pressure which it is ca- 
pable of exerting; thirdly, in its 
ready adaptation to limbs of differ- 
ent dimensions ; fourthly, in the circumstance that it makes pressure 
only at two points — that is, over the artery and at the spot immediately 
opposite to the artery ; and, lastly, the facility with which it may be 
slackened or removed at any stage of the operation. With a little 

Fig. 622. 




Dupuytren ; s compressor. 




Gross's arterial compressor. 



modification, the instrument may readily be adapted to tbe femoral 
artery as it emerges from beneath Poupart's . ligament, or even to the 



650 



ON THE MODES OF ARRESTING HEMORRHAGE. 



external iliac just above this ligament, in amputation at the hip-joint, 
and also to the axillary artery, in disarticulation of the shoulder-joint. 
By a reference to the cut, it will be seen that the instrument is com- 
posed of two blades, differing in the degree of their curvatures, united 
by a screw, and regulated by a ratchet. Each short blade is provided 
with a pad capable of being worked by a screw, and designed to rest 
upon the artery which it is intended to compress. By this arrange- 
ment two tourniquets are produced : a large one for the thigh, and a 
small one for the arm, or the thigh of a small subject." 

Compression is occasionally made over the whole extent of the 
vessel by compresses laid carefully upon its course above the wound, 
and maintained by a roller bandage exercising uniform and regular 
action upon the limb from its extremity to its junction with the body. 
This method is useful in assisting other hemostatic measures, but 
should never be depended upon alone as a definitive dressing. 

Direct pressure upon the mouth of the bleeding vessels by plugging 
the wounds from which the blood issues is sometimes employed, as in 
the hemorrhage following the operation of lithotomy. When the 
blood issues from the vessels of a bone, and other means fail to check 
it, the orifices upon the bony surface may be plugged with wax or a 
piece of soft wood ; fracture of the skull rupturing the middle artery 
of the brain may require the same expedient to arrest the bleeding. 

Direct pressure is, however, painful, excites inflammation, and is 
fatal to union by first intention, and is therefore not to be adopted, 
either provisionally or as an auxiliary to other hemostatic measures 
when the latter will succeed alone. Generally the compresses are satu- 
rated with some astringent before their application. 

Direct pressure once established upon a bleeding artery, the dress- 
ings should not be disturbed, as long as the hemorrhage is checked, for 
seven or fourteen days, according to the size of the vessel. 

The ligature revived by Ambrose Pare' as a substitute for the 
cautery iron is the most efficacious of all the hemostatic means 
employed by surgeons. It has been prepared from 
a variety of materials, silk and linen threads, metallic 
wires, especially those of silver, several sorts of ani- 
mal substances, as catgut, deerskin, etc.; but the 
material now chosen as possessing the most advan- 
tages is well- waxed round silk thread, known under 
the name of saddler's silk. 

When a thread is tied around an artery, it 
divides the inner and middle coats of the vessel, 
as seen in Fig. 623, leaving the external cellular 
coat included in the loop. The blood in the artery 
between the point where the ligature is tied and 
the first collateral branch above, coagulates, plastic 
matter is poured out, and in course of time the clot 
unites with the inner and middle coats, and finally 
this portion of the vessel becomes converted into a 
fibrous cord. The ligature by its pressure causes 
i artery, ulceration of the cellular coat, and comes away, in 



Fig. 623. 




ON THE MODES OF ARRESTING HEMORRHAGE 



651 



from five to twenty -five days, sooner or later, according to the size of 
the artery. We have stated that the rounded silk ligature is generally 
chosen because it makes a clean division of the two interior coats of 
the artery; but in those cases in which the vessel is diseased and 
brittle the ligature must be larger, and the knot not tied so tight, 
otherwise it will cut entirely through. Some surgeons, under these 
circumstances, have preferred to use flat threads, and even to place a 
little compress between the ligature and the artery ; the latter plan is 
objectionable, and has justly been abandoned. 

When the bleeding vessels are divided completely, as in amputation, 
their mouths may be drawn out a little with a tenaculum or the points 
of the forceps, the former instru- 



Fig. 624. 




Mode of tying a ligature. 



ment being more convenient in 
seizing smaller vessels; the ad- 
joining nerves and tissues are 
then to be separated as far possi- 
ble, and the ligatures applied. 

Where the artery lies deep in 
a wound, the ligature is carried 
around it with the instrument 
called an aneurism-needle, which 
has already been described at 
page 43. The vessel should be 
first laid bare, then the needle, 
armed with a ligature, is passed 
beneath it, and after its point has 
emerged towards the orifice of 
the wound, the ligature may be 
seized with the fingers or a pair 
of forceps and drawn out, leaving its centre under the artery. The 
ends of the thread are commonly tied with the sailor's knot, seen in 
Fig. 625. 

The surgeon's knot, shown in Fig. 42, is liable to slip, and should 
not be used in the ligation of arteries. The vessel must not be 
stretched, or drawn from its bed in tying 
the knot; this may be avoided by holding 
the ends of the ligature between the thumb 
and last three fingers of each hand, while 
the index fingers are thrust to the bottom 
of the wound, and placed upon each side 
of the knot to support it during the time 
the ligature is being drawn tight (Fig. 624). 
Should the aneurism-needle not be at hand, 
the eyed probe bent at its extremity may be 
used instead, or even Belloc's sound, which 
is usually found in most all pocket-cases. 

Where the blood comes from an artery in such a position that it 
cannot be isolated, the ligature may be made to include the vessel and 
some of the adjacent tissues; the best instruments for this purpose are 



Fig. 625. 




The sailor's knot. 



652 ON THE MODES OF ARRESTING HEMORRHAGE 



the tenaculum-needle, seen in Fig. 626, and the forceps of Dr. Physick, 
shown in Fig. 627. 



Fig. 627. 



Fig. 626. 




Tenaculum-needle armed with a ligature. 

When the ligature has been put on an artery, one of 
the threads should be cut close to the knot, and the 
other one brought out of the wound at its most depend- 
ing point. 

Wounded veins bleeding freely may also be ligated 
in the same manner as an artery ; where a small ori- 
fice is simply made into their cavities it has been 
recommended to pinch up the margins of the wound, 
and tie them with a thread, thus avoiding the oblitera- 
tion of the entire calibre of the vessel. 

Two ligatures should always be put upon a bleed- 
ing artery if it is possible, one above the wound and the 
other below ; or, if the vessel is cut through, one upon 
each of its extremities. In other cases, where it is im- 
practicable to expose the point of injury, either through 
the original wound, or an incision made for the pur- 
pose, there is but one course left, to put the ligature 
upon the trunk of the artery above the wound. 

Another plan of checking hemorrhage by pressure 
was practised by the ancient surgeons, and in later 
times was laid aside until revived by Prof. Simpson, 
of Edinburgh; we allude to acupressure. It is a valu- 
able addition to the hemostatic means now in the hands 
of the surgeon, is susceptible of varied application, and 
in many cases possesses advantages over the ligature. 
Prof. Pirrie, of Aberdeen, thus describes the prin- 
cipal methods of acupressure : — 

" The first method consists in passing a needle through the flaps, or 
sides of the wound, so as to cross over and compress the mouth of the 
bleeding artery or its tube, just in the same way as in fastening a 
flower in the lapel of our coat, we cross over and compress the stalk 
of it with the pin which fixes it, and with this view push the pin twice 
through the lapel (Fig. 628). The only portion of the needle which is 
left exposed internally on the fresh surface of the wound is the middle 
portion of it, which bridges over and compresses the arterial tube at 
its bleeding mouth, or a line or two or more in the cardiac side of it. 
And if it were a matter of any moment, this part need not always be 



Physick's artery for 
ceps. 



ON THE MODES OF ARRESTING HEMORRHAGE. 653 

left bare, for the needle could often be passed a few lines higher up, 
between the vessel and the cut surface, and, without emerging on that 

Fig. 628. 





Mode of introducing the acupressure needle. 

surface, more or less of both extremities of the needle, viz., its head 
and point, are exposed externally on the cutaneous surface of the side 
or flap of the wound. 

" The second method consists in entering the needle on one side of 
the artery, pushing it behind, causing its point to emerge on the 
opposite side of the vessel, passing a loop of inelastic iron wire over 
its point, bringing the wire over the track of the artery and behind 
the stem of the eye end of the needle, drawing it sufficiently to close 
the vessel, and fixing it by a twist or half a twist around the needle. 
The wire with which the needle is threaded should be twisted, that it 
may be readily distinguished. By means of this twisted wire the 
needle can be pulled out, after which the loop of wire is liberated, and 
can be easily withdrawn. 

" ^he fourth method, or that by a long pin and a loop of passive iron 
wire, is a modification of the third, and differs from it only in a long 
pin, with a glass head, for facilitating its insertion, being substituted 
for the common sewing needle threaded with iron wire. Perhaps of 
all methods the third and fourth are the most secure. The principle 
in each of these is the same ; but Prof. Pirrie says he likes the modifi- 
cation of using long pins, when convenient, from the form of the 
wound, as they can be so quickly introduced, so readily withdrawn, 
and all wriggling and entanglement of different kinds of wire with 
each other avoided. 

"' The fifth method, or that by the twist, may be varied according to 
the extent of rotation of the needle, whether to a half or a quarter 
rotation. The operator has, on the cessation of bleeding, a reliable 
proof that a sufficient degree of rotation has been given to the needle. 
This method may be practised with a long pin or with a threaded 
sewing-needle, and with either it can be very quickly done ; but of all 
methods of acupressure that by the twist with a long pin is the quickest. 
In acupressure by the twist to the extent of a half rotation of the 
needle, the first three movements given to the needle are precisely the 
same as in the third method above described, namely, it is entered on 
one side, pushed behind the artery, and its point is made to emerge 
on the opposite side. The needle is then twisted over the artery and 
fixed on the parts beyond. In this method the artery is, to a certain 
degree, both twisted and compressed. Prof. Pirrie says the first time 
he tried the method by the twist, a half rotation was given to the 



654 ON THE MODES OF ARRESTING HEMORRHAGE. 

needle: but so little pressure when direct is sufficient to arrest 
hemorrhage ; in other cases a quarter rotation was only made by it. 

" The sixth method, or that by transfixion and twist, as hitherto tried, 
in transfixing the tube of the artery, causing the point of the needle 
to emerge on the surface of the wound, giving a quarter rotation to the 
needle, and fixing its point in the tissues beyond the vessel. 

" The seventh method consists in passing a long needle through the 
cutaneous surface, pretty deep into the soft parts, at some distance 
from the vessel to be acnpressed, making it emerge near the vessel, 
bridging over and compressing the artery, and dipping the needle 
into the soft parts on the opposite side of the vessel and bringing out 
the point of the needle a second time through the common integu- 
ment. In this method, the soft parts are twice transfixed, and the 
artery is compressed between the bone and the middle portion of the 
needle without the integument, between the first point of exit and the 
second point of entrance. Three portions of the needle are left with- 
out the integument, namely, its central portion and its extremities." 

Prof. Pirrie says that " the first great point to be determined is, 
whether or not acupressure is a perfectly reliable method of checking 
surgical hemorrhage. That it is so, my belief is as strong as it could 
well be on any surgical point ; and I have a decided impression that 
any surgeon who gives it a fair trial will assuredly arrive at the same 
conclusion. 

"Besides being as reliable as any hemostatic yet employed, it 
appears to me to have the advantages of being the quickest, the 
easiest of application, and the safest means yet devised for arresting 
bleeding. That the vessels in a large amputation can be acupressed 
in a much shorter time than they can be ligatured I am perfectly 
satisfied ; and in cases where every drop of blood is precious, it seems 
to me that to do all that can be done to preserve life, as far as saving 
of blood has influence, it is the duty of the surgeon in all suitable 
operations to give his patient the benefit of this new proceeding. But 
shortening the period occupied in arresting hemorrhage is not only 
important for diminishing one of the early dangers of an operation — 
namely, that from loss of blood — but also for lessening the risk of the 
more remote dangers of suppuration, and many distressing results of 
the higher grades of the inflammatory process in the stump. I have 
long thought we are too apt to forget that living tissues are resentful 
of even slight injuries, and that we are not sufficiently careful to use 
the sponge as seldom, and as gently as possible. Whatever shortens 
the period of hemorrhage must diminish the risk from frequent touch- 
ing of the parts." 

Tortion, once lauded as an efficient hemostatic means, is now aban- 
doned except in its application to vessels of the smallest calibre. It 
consists in drawing out the mouth of the bleeding vessel with a pair 
of forceps about half an inch (Fig. 630) ; a second pair of forceps is 
now used to seize the artery at right angles to its axis and at its point 
of emergence from the surface, to hold it firmly while the vessel is 
being twisted upon itself by the first instrument made to revolve upon 



ON THE DRESSINGS OF WOUNDS. 655 

Fig. 630. 




Tortion of an artery. 



its axis. In this manner, by seven or eight turns of the forceps, the 
middle and inner coats of the artery are ruptured and twisted in a 
knot which is to be returned into the wound. 



CHAPTER XVI. 

ON THE DRESSINGS OF WOUNDS. 

The dressings required by wounds will vary according to their 
nature, position, and complications ; and it will, therefore, be conve- 
nient to consider them under the separate headings of incised, punc- 
tured, lacerated, contused, and gunshot wounds. 

Incised Wounds are solutions of continuity produced by sharp- 
edged instruments, such as a knife, hatchet, or sabre. They vary in 
length and depth from the smallest cuts with the edge of a penknife 
to those large incisions sometimes following blows with a sabre. 
These wounds may occupy any part of the body, and extend in any 
direction with its axis — transverse, longitudinal, or oblique. The 
local symptoms which characterize them are hemorrhage, pain, and 
separation of the lips of the wound. 

The hemorrhage is always considerable when the incision is of 
any extent, or penetrates to some depth ; the blood flowing immedi- 
ately and freely from the orifices of the divided capillaries and arteries, 
which, if they are few and of the smallest size, soon contract upon the 
application of cold or astringent substances and cease to bleed ; while, 
on the other hand, the blood will gush out in a copious stream if the 
large arteries are involved until the patient faints ; and the hemorrhage 
will always prove fatal unless arrested by appropriate hemostatic 
measures. 

The pain of incised wounds results from the division of the nervous 
filaments distributed to the part, and will vary in intensity according 
to the position of the wound, and the number of nerve filaments 
divided. In general, those seated upon the anterior plane of the body 
are more painful than those upon its posterior plane ; and from the 
large supply of nerves to the face and palms of the hands, wounds of 



656 ON THE DRESSINGS OF WOUNDS. 

these regions will also be very painful. The condition of the patient's 
mind at the time of the injury will have an important influence upon 
the degree of pain felt. When a person, for instance, is sharply en- 
gaged in a contest, with all his energies bent to the task of vanquishing 
his enemy, he may have a wound inflicted upon him and not feel it, 
or even know that the accident has occurred until he sees the blood 
flow. 

The separation of the lips of the wound is a striking feature of this 
sort of injury, and it will take place in various degrees, depending on 
the shape of the instrument that inflicts the wound, the tension of the 
part at the time that it is inflicted, the elasticity of the tissues, and the 
amount of musclar contraction. The first circumstance — the shape of 
the instrument inflicting the injury — will influence the width of the 
gap by simply acting mechanically, the weapon serving as a wedge to 
force open the incision. The amount of separation caused in this way 
is always small, and in most cases is inappreciable ; so also is that 
resulting from the tension of the part at the time the injury is received ; 
for the moment the tension is removed, the edges of the wound 
approximate as far as the elasticity of the tissue and the muscular 
contraction will permit them. 

The purely physical property of elasticity possessed by the textures 
plays a much more important part in causing wounds to gap than 
those hitherto mentioned. Its influence is well seen in incised wounds 
of the skin, which is the most elastic portion of the body ; the margins 
of the incision open widely, displaying the structures beneath, which, 
though influenced to a certain extent by their elasticity, are much less 
so than the skin, and their borders do not, therefore, separate to an 
equal degree; the wound will in consequence possess a conical shape 
with its base at the surface. Muscular contraction excited by the 
wound, also, has an important agency in drawing its lips asunder, and 
its influence is most marked immediately after the infliction of the 
injury. 

In the treatment of incised wounds, the indications are to remove 
all foreign matters that may have gained admission into them ; to arrest 
hemorrhage, and to bring their edges into accurate contact. 

The removal of foreign bodies may be accomplished by causing a 
stream of water to run over the wound ; any particles that are visible 
may be seized and withdrawn with the forceps. Clots of blood are 
also equally inimical to union by first intention, and should be care- 
fully cleared away from the wounded surfaces. 

Hemorrhage is to be controlled by the means we have already 
pointed out in the previous chapter. 

The third indication, that of bringing the wounded surfaces together 
and keeping them in accurate contact until they may have united, is 
effected in several ways, which require special description. 

1. Position. — Position exercises an important influence in maintain- 
ing the edges of a wound approximated. In all cases, before recourse 
is had to other measures, the wounded part should be put in that posi- 
tion which permits the easiest approach of its margins, and this, of 
course, will vary with the situation and direction of the wound. If 



ON THE DRESSINGS OF WOUNDS. 657 

the incision is transverse to the extensor muscles of the extremities, 
the position of extension is required ; while in a similar injury of the 
flexors perfect relaxation is only to be attained by flexing the limb. 
In longitudinal wounds of the extensors, Boyer advised the limb to 
be flexed, and the reverse in similar wounds of the flexor muscles ; 
but in this case, as the sides of the wound might be painfully drawn 
upon, it would be better to keep the limb straight, and the muscles 
in a state of equilibrium, depending rather upon adhesive strips and 
sutures to sustain the margins of the wound together. 

2. Agglutinatives. — We have already considered, in Part L, the 
various kinds of agglutinatives — adhesive plaster, collodion, water- 
glass — and the mode of their application. 

When using adhesive strips in the approximation of the borders of 
wounds, the parts should be shaved and cleansed before the applica- 
tion of the plaster ; the strips are then laid over the wound after it 
has been drawn together, about a quarter of an inch apart, so that the 
blood or secretions may have ready egress. The strips need not be 
changed, as long as they serve their purpose, until cicatrization takes 
place; though usually at the end of three or four days, from the 
quantity of the discharge from the wound, from the plaster loosening, 
or from other causes, their removal becomes necessary. This must be 
accomplished with care, that the wound be not disturbed. The best 
plan is to seize one of the extremities of the strip in the fingers, and 
detach it as far as the wound ; then in like manner treat the other 
extremity, so that the body of the strip shall be the last part removed. 
But one strip should be taken off at a time, and a new one immediately 
substituted for it, until the dressing is completed. If, upon examina- 
tion, the strips are found not to require changing, the wound may be 
simply cleansed by allowing warm water to flow over it from a sponge 
held just above, which, combined with gentle pressure, will suffice to 
remove all the secretions in and about it. 

M. Chassaignac has derived great benefit from his mode of dressing 
all descriptions of wounds by the prolonged application of strips of 
adhesive plaster. "This plan had been put into successful operation in 
respect to wounds accompanying comminutive fractures, large ones 
accompanied with laceration of tendons and aponeuroses, and wounds 
resulting from burns, bites of animals, amputations, and resection, &c. 
Since that period the same practice has been followed by him, and 
with the following results. 1. The immediate diminution of the trau- 
matic pain in almost all cases. 2. The absence of traumatic fever in 
the majority. 3. Diminution in the amount of suppuration — an im- 
portant point in the case of large burns and extensive wounds. 4. 
Prevention of the irritation, and numerous other inconveniences 
attendant upon the daily exposure of the wound for the purpose of 
renewing the dressing. 5. The much greater rapidity of the cica- 
trization, due to the amelioration in the character of the suppuration, 
the diminution of the inflammation, and especially the keeping the 
edges of the wound upon a level with its surface. 

"This mode of dressing, as applied by M. Chassaignac, consists in 
the formation of a kind of cuirass over the wounded part, by means of 
42 



658 ON THE DRESSINGS OF WOUNDS. 

strips of adhesive plaster overlapping each other, and generally dis- 
posed in the form of an X. This artificial integument is covered with a 
piece of rag, perforated with holes, thickly spread with cerate, and 
everywhere extending beyond the plasters. This rag, covered with 
charpie, is kept in situ by compresses and bandages. This dressing 
remains on for eight or ten days. If there is too abundant a suppu- 
ration, the whole of the apparatus is renewed, with the exception of 
the plasters, which are not to be removed. During these eight or ten 
days the condition of the wound thus concealed is explored by means 
of gentle pressure made over the wound through the cuirass, or along 
the course of the lymphatics, the bloodvessels, the tendinous sheaths, 
and the principal nerves. If inflammatory action is present, a free 
application of leeches, made either in the vicinity or at a distance 
from the wound, suffices to disperse it. 

"The two objects to be kept in view during the treatment by 
occlusion are, the keeping the surface of the wound itself constantly 
covered, and the disposition of the strapping so as to allow the dis- 
charge a free escape. But the surgeon must not imagine that when 
he has once applied the strapping, especially in the case of consider- 
able lesions, as in compound fractures, the wounds from operations, 
crushing of the fingers, &c, he is dispensed from bestowing the greatest 
attention upon the progress of the case. Thus, if he does not daily 
expose the plaster to view, carefully examine by gentle pressure the 
condition of the subjacent parts, expel, by pressing towards the most 
depending parts, all accumulations of pus, carefully cleanse all parts 
of the cuirass contaminated by the pus, support by new strips any 
enfeebled part, and divide any of those which seem to be making 
injurious pressure, he will only spoil a good measure by his faulty 
application of it." (Medico -Chirurgical Review, Jan. 1860.) 

3. Position, aided by the agglutinatives, will in many cases secure 
the retention of divided surfaces in contact most perfectly ; where the 
wounds are deeper, in addition to these, compression with suitable 
bandages will be required. We have already described the uniting 
bandages for transverse and longitudinal wounds at page 212, which, 
at the same time that they draw together their edges, make more or less 
compression. In some cases the object may be accomplished better by 
placing two compresses along either side of the incision, and securing 
them by a roller bandage extending from the toes or fingers to the 
root of the limb ; in other instances, immovability and compression 
of the part may be secured most elegantly and efficiently by the 
starched bandage, taking care that no constriction ensues from inflam- 
matory swelling. 

Sutures are more often employed to bring the margins of wounds 
in contact, when they are of greater extent, and require, besides this 
approximation of their edges, that the parts beneath be supported. 
The principal sorts of suture used by the surgeon are the interrupted, 
continued, twisted, and quilled. 

The interrupted suture is made with a curved or straight needle, 
armed with a metallic or a well-waxed silken or hempen thread, of a 
thickness proportioned to the size of the wound. One of the margins 



ON THE DRESSINGS OF WOUNDS. 



659 



of the incision is steadied with the thumb and index finger of the left 
hand, while, with the right, the needle is caused to perforate it from 
without inwards. The point of the needle is again entered upon the 
inner face of the opposite margin, and carried from within outwards to 
pierce the skin at a distance from the wound equal to that of its point 
of entrance. In this manner the required number of sutures are 
introduced from a half to three-quarters of an inch apart, and their 
ends are then tied with the reef-knot, as seen in Fig. 631, without, 
however, constricting the tissue inclosed in the loop ; the knots should 
be upon the side of the incision, and not over it, as shown in the figure. 
In superficial wounds, the threads should not pass through the fibrous 
or muscular tissues ; while, in other cases, their depth must be such as 
to secure the closest approximation of the wound. The distance at 



Fig. 631. 



Fig. 632. 




The interrupted suture. 



The continuous, or Glover's suture. 



which the needle is entered from the incision 
will also vary with its extent, from two or three 
lines to a quarter of an inch. 

The continuous suture is executed, as in the 
previous instance, with a needle and thread. 
The needle is pressed obliquely through both 
margins of the wound, its point entering upon 
the same side at every stitch, so that the thread 
describes a spiral between the extremities of 
the incision. This suture is principally em- 
ployed in wounds of the intestines and abdo- 
men (Fig. 632). 

The twisted suture requires pins or straight 
needles, with spear points, such as are seen in 
Figs. 633 and 634; the former being the old 
form of needle used in hare-lip, and the latter 
the new and improved one. The best material 
of which to prepare these needles is gold, as it 
does not become oxidized and irritate the parts, 
or adhere to them when incrusted with dried 
blood or pus. The needles most commonly em- 



Fig. 633. Fig. 634. 



NeedJes for twisted sutures. 



660 



ON THE DRESSINGS OF WOUNDS, 



ployed, however, are those made of steel, of the shape seen in Fig. 634. 
The suture is made in this manner : The lips of the wound are held 
in accurate contact, and then the needle or pin held in the fingers or 
forceps is passed through them both, at that point first where it is most 
important to obtain union ; then, in succession, other needles are intro- 
duced in like manner at convenient distances until a sufficient number 
has been used. The surgeon now takes a piece of thread in both hands 
and entwines its loop around the first pin in the form of an ellipse, or, 
what is more common, in the form of a figure of 8 (Fig. 635). The 
threads are then crossed over the intervening space, and a figure of 8 
made upon the second pin, and so on until they are all encircled with the 
threads. The points of the pins must then be cut off with the pliers 
(Fig. 636), that they may not wound the patient, or catch in the clothes. 



Fig. 635, 



Fig. 636. 





Twisted or hare-lip suture. 



Pin-pliers. 



At the end of three or four days, or earlier, according to the cir- 
cumstances of the case, when the suture is to be removed, the pins 
are to be seized by their heads with a pair of forceps and drawn out, 
while the thread is supported by the point of the left index finger. 
The thread either falls at the same time, or, what is more common, 
remains sticking to the skin two or three days longer. 

A very elegant modification of the twisted suture has been recently 



Fig. 637. 



Fig. 638. 





Iudia-rubber suture. 



Quilled suture. 



ON THE DKESSINGS OF WOUNDS. 661 

introduced into practice by M. Gariel, consisting in the substitution 
of little India-rubber rings for the threads, and applied as seen in 
Fig. 637. The rings are obtained from sections of India-rubber tubes 
of any desired size. 

The quilled suture (Fig. 638) is made by passing through the edges of 
the wound a number of double threads at intervals of about an inch, 
with a curved needle — or, better, with the tenaculum-needle. A quill, 
piece of bougie, or a slender stem of wood is put under the loops 
formed by the threads upon one side of the wound ; the extremities 
of the threads are then separated, and "a piece of bougie placed be- 
tween them, over which they are to be tied sufficiently firm to hold 
the margins of the wound in contact. 

In removing this suture, which is principally used in rupture of 
the perineum, it suffices to cut the loops, when the threads may be 
readily withdrawn. 

What is called the dry suture, consists in fastening along the mar- 
gins of a wound two narrow strips of adhesive plaster, and then 
sewing their contiguous margins together. 

There are other forms of suture used in special cases — such as the 
tongue and groove suture of Prof. Pancoast ; the button suture of Dr. 
Bozeman, and the clamp suture of Dr. Sims, a description of which 
does not fall within our limits. 

M. Vidal has invented an ingenious little instrument for maintain- 
ing the edges of a wound together, and for which he 
was awarded a prize by the Institute of France. It Fig. 639. 
is made of fine silver wire, bent in the form seen in 
Fig. 639. The points are toothed so that they will 
take firm hold upon the margins of the incision, and 
sustain them in contact by the spring of the wire. 
The instrument acts very superficially, and cannot The serrefine. 
be used in wounds of any depth. 

Under the most favorable circumstances, when the edges of incised 
wounds have been brought into exact apposition, their union may 
take place by immediate adhesion, that is, no inflammation will be de- 
veloped, or effusion of plastic matter occur; but the continuity of the 
fibres, bloodvessels, and nerves will be immediately re-established, and 
no cicatrix will remain. 

Another mode of healing, sometimes observed, is that called by 
McCartney the " modelling process ;" it consists in the breach in the 
tissues being repaired, without inflammation, under a covering or scab 
formed by the concretion of blood or the secretions of the part ; or, 
an artificial crust may be formed with gum Arabic or any other bland 
absorbent powder. 

Union may be effected in a third mode, or by adhesive inflamma- 
tion; the margins of the wound become moderately inflamed and 
swell a few hours after the injury, and a reddish plastic fluid is effused 
between them, which is promptly organized into -a bond of union. 

Should the degree of inflammation surpass that required for the 
formation and organization of the effused plasma, the surfaces of the 
wound become covered with a yellowish-white vascular membrane 



g$#0\ 



662 ON THE DRESSINGS OF WOUNDS. 

studded with small projecting points called granulations, which are 
enveloped with pus. 

If now these granulations are kept in accurate apposition, they 
may unite, constituting what is called. union by second intention. 
When the granulating surfaces are not brought together, but left 
exposed to the air, the membrane covering them acquires increased 
thickness, and contracts, drawing their margins towards the centre of 
the wound, while the granulations now level with the surface become 
smaller, and those at the circumference of the wound covered with a 
thin bluish pellicle which gradually extends towards the centre until 
the whole surface is covered with a cellulo-fibrous membrane called 
a cicatrix. 

B. Contused Wounds are produced by blunt weapons, such as a 
club, by the passage of a wheel over the body, or by gunshot; the 
parts are torn or braised in various degrees from the mere laceration 
of the skin and a few small bloodvessels to the complete disorganiza- 
tion of muscles, bloodvessels, and bones. In the latter case, there is 
always great shock inflicted upon the system ; the patient is prostrated 
with a feeble pulse, bleached skin, and cold extremities, and when 
reaction set in, will frequently vomit. 

From the damage done to the nerves there will generally be con- 
siderable pain felt unless the parts are disorganized, when it may not 
be present at all; the bloodvessels being bruised, the blood will 
speedily coagulate in them and prevent hemorrhage. 

The margins of the wound are generally irregular, torn, and infil- 
trated with blood. 

When the injury is inflicted without breaking the skin, it is called 
a contusion, in which the smaller vessels only may be torn, giving 
rise to an infiltration of blood beneath the skin, or ecchymosis ; or 
larger arteries will sometimes be involved and the blood escape in 
greater or less quantity so as to form collections of different magni- 
tudes, from the size of a small nut to that of an infant's head, or even 
larger. 

In the treatment of contusions the object will be to check inflam- 
mation, and subsequently to promote the absorption of the effused 
blood. The first indication is fulfilled by the application of leeches, 
cold water-dressings, solutions of the acetate of lead and opium, or a 
mixture of alcohol and water; and the second by stimulating infric- 
tions of camphorated alcohol, tincture of arnica, or such like sub- 
stances. Under this treatment the ecchymosis will usually disappear 
in a few days ; large collections of blood may be removed by a small 
incision through the skin. In contused wounds, such of the lacerated 
parts as possess vitality should be thoroughly cleansed and brought 
together by suture and adhesive strips. If there is any hemorrhage, 
it must be suppressed by the means we have already pointed out. 
Inflammation must be kept down by the use of cold applications ; or, 
when pretty active, leeches may be had recourse to. During the time 
that the sloughs are separating, secondary hemorrhage may occur, 
and should be met by appropriate measures. 

C. Punctured Wounds. — These wounds are inflicted by such in- 



ON THE DRESSINGS OF WOUNDS. 663 

struments as the sword, bayonet, lance, knife, nails, splinters of wood, 
or any other sharp-pointed and hard body. If these instruments are 
slender, well polished, and sharp, they penetrate the body by sepa- 
rating the fibres of the tissues, and there will be little or no lacera- 
tion ; while other objects that are rough, thick, or blunt, will produce 
more or less contusion in tearing their course through the soft parts. 

Punctured wounds will vary much in character, according to their 
position, extent, and the nature of the instrument with which they 
have been inflicted. 

The pain which accompanies them is most generally very severe, 
especially when they are produced by some rough object, and occupy 
a position among the fasciae, or parts abundantly supplied with nerves. 
There is rarely any amount of blood observed to flow from the punc- 
ture, and should a large artery be perforated, the hemorrhage will 
occur in the surrounding tissues, forming traumatic aneurism. 

This variety of wound is the one most often followed by such com- 
plications as abscess, tetanus, erysipelas, &c. 

The indications of treatment in punctured wounds are to remove 
all foreign bodies from them with the fingers or forceps, assisted, if 
necessary, by appropriate incisions; to check hemorrhage by the 
application of compressors, ligature, or other hemostatic means ; and. 
to control inflammatory action by the use of local antiphlogistics. 

D. Gunshot Wounds. — Gunshot injuries are contused and lacerated 
wounds produced by the explosion of fire-arms, as pistols, rifles, can- 
non, &c. They are of different degrees of gravity, according to their 
extent, location, and the character of the projectile by which they 
have been occasioned. In most cases there will be more or less shock 
produced by the injury. The pain is not great as a general rule : and 
I have seen a number of instances in which the limb was perforated 
by a Minie ball and the bone shattered, yet there was no pain : the 
patient complained only of a feeling of weight in the part as long as 
it remained quiet. Lulled into a sense of false security by this absence 
of pain, patients have often become the victims of their own impru- 
dence, in their great anxiety to save their limbs, by declining surgical 
interference at the opportune moment ; and not until the lapse of three 
or four days, when inflammatory action has set in and the limb becomes 
swollen and painful, do they feel the futility of their hopes and the 
rashness of their conduct. 

The hemorrhage from gunshot wounds is usually small; sometimes, 
however, a large artery may be divided by a ball moving with great 
velocity, and copious bleeding follow. What the surgeon has most 
to fear in this respect is secondary hemorrhage, which generally takes 
place between the fifth and twenty-fifth days. In either case the im- 
perative rule is to ligate both extremities of the artery, should it be 
possible ; if not, put the ligature upon the trunk above the wound. 

The injury should be examined as soon as practicable after its in- 
fliction, and all foreign bodies removed from it, such as bullets, pieces 
of clothing, fragments of shell, &c. The best probe, if it can be used, 
is the finger, which should be gently introduced, and all parts of the 
wound fully explored with it ; in other cases a stout probe (Fig. 27, 



664 



ON THE DEESSINGS OF WOUNDS, 



p. 41), eight or ten inches long, may be employed to penetrate to 
greater depths than can be reached with the finger ; a straight silver 
catheter may be used for the same purpose. If a leaden object is 
present, a very ingenious method of detecting it is with Nelaton's 
probe, which is simply a long metallic stem tipped with a little ball 
of unglazed porcelain ; the slightest contact of the ball with the metal 
will produce a black stain. MM. Fontan and Favre recommended for 
the detection of metallic objects an explorer composed of two insulated 
wires connected with a single cup of Sniee's battery ; the explorer 
coming in contact with the metal, establishes a galvanic current, which 
is indicated by the deflexion of a galvanometer attached to the appa- 
ratus. The plan is ingenious, but entirely destitute of practical utility. 
For withdrawing bullets and other objects, the most useful instru- 
ment will be a pair of long, slender-bladed forceps, such as are seen 
in Fig. 640. Should the body be felt beneath the skin, an incision 



Fig. 640. 




Fig. 2 




Kolb6's bullet-forceps. 



Bullet-forceps. 

must be made upon it, and the body turned out of its bed with the 
finger or forceps; the rule to follow, in such cases, being to remove 



AXJESTHESIA 



665 



Fig. 642. 



all foreign matter from that point of the surface to which they are 
nearest. The bullet-forceps of Mr. Kolbe, a skilful instrument-maker 
of Philadelphia, may also be employed to remove bullets. It consists, 
as shown in Fig. 641, of a metallic tube with two short serrated jaws 
articulated with one of its extremities, and capable of being expanded 
or closed by turning a screw placed at the other. The instrument is 
introduced closed, and may be used as a probe ; 
when the bullet is felt, it is at once grasped by 
opening the jaws of the forceps. 

The instrument sketched in Fig. 642 has a 
movable point, which may be bent by the stem 
running through the tube, at a right angle with 
the latter. The extractor is introduced into the 
wound beyond the object, when its point is thrown 
down, as seen in the figure. The inner surface 
of the point is concave, to embrace the ball. 

When the missile is buried in the bone, it 
may require the use of the trephine or gouge to 
remove a sufficiency of it adjoining the ball to 
allow the forceps to get a good hold upon the latter. The sharp- 
pointed screw, so much employed in former times for extracting balls, 
is now justly abandoned. 

After the foreign bodies have been removed and the wound tho- 
roughly cleansed, its sides must be supported with adhesive plaster, 
or compresses and a roller bandage. To control subsequent inflam- 
matory action, cold water-dressings will generally be found most 
agreeable; and should sloughing impend, they must at once be aban- 
doned for warm applications. When there is any burrowing of pus, 
free incisions should be made to evacuate it. 




Bullet-extractor. 



CHAPTER XVII 



ANESTHESIA. 



The minds of surgeons had been from a remote period engaged in 
fruitless efforts to discover some means of preventing pain during sur- 
gical operation; but it was not until the year 1847 that success 
crowned their exertions. This desideratum must have been felt by the 
older surgeons, previous to the revival of the ligature as a hemos- 
tatic agent by Ambrose Pare', much more severely than since that 
period ; for to check a hemorrhage, now controlled by a single thread, 
the only means in their possession were the red-hot knife, or the searing 
cautery ; and sometimes bleeding stumps were thrust into pots of boiling 
pitch. Such means might well cause the most resolute and enduring 
to recoil from the severities of a surgical procedure, especially when 
nothing beyond the temporary numbing of the sensibilities by opium 
or other narcotic could be obtained. 



666 ANESTHESIA. 

Local Anesthesia. — The methods that have been employed to 
produce local anaesthesia at different periods may be considered under 
three heads : Compression, local narcotization, and refrigeration. 

Compression has been made in two ways, either directly upon the 
part to be incised, or upon the trunk of the nerve leading from the 
limb. In the first instance we see an illustration of the numbing in- 
fluence of pressure in the anaesthetic effect of pinching the edges of a 
wound between the fingers before passing the needle through them in 
making a suture. Compression upon the trunk of the nerve was par- 
ticularly brought forward by Mr. John Moore, of London, who invented 
an instrument for the purpose analogous to the compressor of Dupuy- 
tren already described ; one of the pads of the instrument was placed 
over the sciatic, and the other over the crural nerve : several opera- 
tions were performed upon the lower extremity, while the apparatus 
was applied, but anaesthesia was so imperfectly attained that that plan 
was soon abandoned. 

Local narcotization was long ago practised for the object of annihi- 
lating pain during operations. M. Bouisson states that he applied a 
plaster of opium to the toe of a patient for some time, and afterwards 
succeeded in partially tearing away the nail without causing pain ; he 
was also in the habit of using belladonna ointment to relieve the pain 
of the operation for fissured anus. A plan was pursued some years 
ago of smearing bougies, catheters, etc. with narcotic ointments, while 
dilating, cauterizing, or incising stricture of the urethra. 

Eefrigeration may be produced in several ways. The old plan 
was to apply to the parts demanding surgical interference, various 
frigorific mixtures, usually ice and one of the salts of sodium or potas- 
sium; equal parts of pounded ice and common salt is as good a mix- 
ture as any other for this purpose. Its anaesthetic effects are restricted 
to the skin and cellular tissue, and will not, therefore, be available in 
operations requiring the incision to go deeper than those structures. 
I have used it in opening buboes, abscesses, and in superficial inci- 
sions with success. 

A simple apparatus is required in applying the ice mixture; a pig's 
bladder, or a piece of oiled silk ; the temperature must be brought 
below 32° Fahr., perhaps between 15° and.25° will be as safe, which 
will produce the requisite degree of anaesthesia in from fifteen to twenty 
minutes. 

This method may be employed where the apparatus of Mr. B. W. 
Eichardson is not at hand, and it will answer very well in the class of 
cases above mentioned. 

The ingenious contrivance of this gentleman leaves little to be 
desired for the convenient and efficient application of cold in the pro- 
duction of local anaesthesia. The apparatus which he originally 
devised consisted " simply of a graduated bottle for holding ether ; 
through a perforated cork a double tube is inserted, one extremity of 
the inner part of which goes to the bottom of the bottle. Above the 
cork a little tube connected with a hand bellows pierces the outer part 
of the double tube, and communicates by means of the outer part by 
a small aperture with the interior of the bottle. The inner tube for 



ANESTHESIA.. 667 

delivering the ether runs upwards nearly to the extremity of the outer 
tube. Now, when the bellows are worked, a double current of air is 
produced, one current descending and pressing upon the ether, forcing 
it along the inner tube, and the other ascending through the outer 
tube, and playing upon the column of ether as it escapes through the 
fine jet." 

This instrument has been farther improved by substituting for the 
bellows two India-rubber balls, which render it more convenient and 
portable, without destroying the efficiency of its action. 

"By this simple apparatus, at any temperature of the day, and 
at any season, the surgeon has thus in his hands a means for pro- 
ducing cold even 6° below zero ; and by directing the spray upon a 
half-inch test-tube containing water he can produce a column of ice in 
two minutes at most. Further, by this modification of Siegle's appa- 
ratus he can distribute fluids in the form of spray into any of the 
cavities of the body — into the bladder, for instance, by means of a 
spray-catheter, or into the uterus by a uterine spray-catheter." 

'• When the ether spray thus produced is directed upon the outer 
skin, the skin is rendered insensible within a minute ; but the effects 
do not end here. So soon as the skin is divided, the ether begins to 
exert on the nervous filaments the double action of cold and of ether- 
ization ; so that the narcotism can be extended deeply to any desired 
extent. Pure rectified ether used in this manner is entirely negative ; 
it causes no irritation, and may be applied to a deep wound, without 
any danger. I have applied it direct to the mucous membrane of my 
own eye, after first chilling the ball with the lid closed." 

Eeaction from the anaesthesia is in no degree painful, and hemor- 
rhage is almost entirely controlled during the anaesthesia. 

One or two precautions are necessary. It is essential, in the first 
place, to use pure rectified ether; methylated ether causes irritation, 
and chloroform, unless largely diluted with ether — say, one part in 
eight — does the same. 

General Anesthesia. — Various plans have been suggested and 
tried from an early period in the history of surgery, to render patients 
insensible during the performance of surgical operations. The ancients 
used the root of the mandrake steeped in wine; Theodoric, in the 
thirteenth century, recommended the inhalation of opium, and in 1538 
we find Canappe imitating Theodoric in using narcotics by inhalation 
for the same purpose. 

Sir Humphry Davy, in 1799, remarked that " as nitrous oxide, in 
its extensive operation, appears capable of destroying physical pain, 
it may probably be used with advantage in surgical operations." 

In 1844, Dr. Horace Wells employed the nitrous oxide in his own 
case, having a tooth extracted painlessly ; he afterwards gave it to 
several patients upon whom a similar operation was performed, with 
the most gratifying success. 

Mesmerism was practised by Dr. Esdaile, a surgeon in India, and 
he states that he had submitted patients under its influence to the 
larger operations without causing them the slightest pain. 

Hypnotism, a name given by Mr. Braid to a sort of somnambulic 



ANAESTHESIA. 

sleep produced by intently gazing at a bright object, has also been 
had recourse to for the purpose of producing anaesthesia. 

Both of these processes are uncertain in their operation and of little 
or no practical use to the surgeon. 

Ether was first used as an anaesthetic by Dr. Morton, a dentist of 
Boston, in 1834, for the purpose of preventing pain during the ex- 
traction of teeth. 

He afterwards etherized two patients undergoing surgical operations, 
one for Dr. J. C. Warren and the other for Dr. Haywood. 

Since that time it has been employed in every portion of the civilized 
world, and, mixed with chloroform — usually three parts of the former 
to one of the latter — is generally preferred for anaesthetic purposes 
by American surgeons. Some, however, still give the preference to 
chloroform, and during the late war it was more commonly used than 
ether by the military surgeons, and given in thousands of cases with 
the most gratifying results. 

I have used it in many cases, and never saw any bad effects follow. 
In those patients, even, who had suffered severe shock chloroform 
was often employed as a stimulant along with brandy, and where im- 
mediate operations were required no unnecessary time was lost from 
any fear that its administration would add to the depression already 
present from the injury. 

Up to the present time there have been but few instances of death 
following the use of ether, while chloroform reckons among its victims 
some hundred or more. Various reasons have been assigned for this 
difference. The fact that chloroform is more energetic than ether is 
undoubted, and that it requires greater care in its administration to 
insure security from accident is also certain ; and, lastly, it has been 
observed that it may undergo changes by exposure to light and heat, 
so that poisonous compounds are developed by the chemical reactions 
following. 

To a want of proper attention to the first point mentioned, at the 
introduction of chloroform into surgical practice, may be attributed 
some of the fatal cases. Too large a quantity of the agent being used 
without due regard being paid to the admission of air. Other cases 
resulted from syncope, by giving the chloroform while the patient 
was in an erect posture, thus opposing to the action of an already 
enfeebled heart, the retarding influence of gravity. Under this head, 
perhaps, fall the unfortunate cases (which are by no means an incon- 
siderable portion of the whole number) of the dentists. 

As to the third point — chemical changes in the chloroform pro- 
ducing poisonous compounds — it is recorded that this anaesthetic was 
given during the Crimean War in 12,000 cases, with but one death 
resulting from the agent, and in this instance the chloroform used was 
in a forward state, of decomposition ; from the want of any other evi- 
dence of the cause of the fatal termination, death was attributed to 
the poisonous compounds developed by these chemical changes. 

Latterly we hear unfrequently of fatal cases from the use of chloro- 
form, and this infrequency will amount to total immunity when the 
importance of the three foregoing facts is fully recognized and 



ANESTHESIA. 669 

properly attended to. In other words, chloroform in proper quantity, 
of good quality, and carefully administered, may be as safely used in 
operative surgery as ether. 

That chloroform will ever be supplanted by any anaesthetic yet 
discovered is quite improbable ; and the success which has attended 
its employment in thousands of cases of surgical operations, during 
the war of the rebellion, has given the uprising generation of surgeons 
a confidence in the value of this agent that must remain unshaken. 

Mr. Arnott, of London, the champion of local anaesthesia, has 
endeavored to prove, by statistics, that since the introduction of the 
anaesthetics the mortality after surgical operations has been materially 
increased. But all statistics drawn from a comparison of total operations 
of all classes before and after the employment of these agents will not 
fairly settle the question of the relative mortality, inasmuch as with 
the anaesthetics, surgeons have been enabled to bring within the limits 
of application of the knife a large number of operations that had 
hitherto been rarely, or not at all, attempted, and among which there 
was necessarily a large number of fatal cases. 

The only proper method would be to compare the same classes of 
operations with each other performed before and since the discovery 
and use of the anaesthetics; that is, amputations with amputations, 
lithotomy with lithotomy, &c. 

It is my opinion, based upon the observations of numerous cases 
during the war, that the use of chloroform improved the chances of 
recovery by diminishing the shock of the operation and giving the 
surgeon another advantage of no mean value, namely, complete control 
over the patient so that he may proceed with his incisions with 
accuracy, certainty, and a reasonable amount of leisure. 

It has been stated that chloroform changes the character of the 
blood and diminishes the tone of the capillaries, thereby giving rise 
to a greater frequency of secondary hemorrhage after operations. 
This result did not occur as far as I was enabled to judge in any of 
the cases that came under my observation, although chloroform was 
invariably employed when operative interference was required, and 
particular attention was paid to this point with a view of ascertaining 
the actual influence exercised by the agent iu this respect. 

The inhalation of chloroform should be avoided in operations about 
the jaws and fauces where it may happen that in consequence of the 
insensibility of the patient the blood will flow into the glottis and 
produce suffocation. Ether, producing a much less sedative effect 
upon the heart's action, will be preferable in those cases in which 
operations are to be performed upon patients in a sitting posture, or 
where it is desirable to induce only a partial anaesthesia, that the 
patient may cooperate with the surgeon during the performance of 
operations about the throat. 

When chloroform is being employed the patient should always be 
placed in a recumbent position. About a drachm of the agent is poured 
upon a towel folded in the shape of a cone and held over his nose and 
mouth, some little distance from the face, that the air may be freely, 
mixed with the vapor as it passes into the respiratory passages,. 



670 ANESTHESIA. 

I often administered it by directing a small piece of cotton cloth 
to be laid over the patient's nose and mouth, and the chloroform 
dropped upon this in small quantities at a time, until the desired effect 
was produced ; the cloth being thin, permits the air to reach the lungs 
through its meshes in due quantity. In order to prevent the loss of 
the chloroform by evaporation, in adopting this plan, I usually cover 
the cloth with a piece of oiled silk of corresponding size ; the lower 
margins of the two pieces must be raised a little, so that the air may 
gain ready access with the chloroform during the inhalation. Eapid 
anaesthesia, economy of the chloroform, and an abundant supply of 
air are the advantages of the plan; it may also be mentioned that the 
eyes and face are freed from the contact of the liquid. 

When the patient has been fully chloroformized, the inhalation 
should be momentarily suspended, and afterwards resumed at the 
moment the patient shows signs of returning consciousness, which 
will be evinced by some muscular effort. The quantity of chloroform 
poured upon the towel needs to be diminished at every dose. In 
this manner anaesthesia may be safely maintained for several hours 
together ; during this time the patient should be narrowly watched, 
an assistant being detailed to note the pulse and at the same time 
attend the appearance of the countenance and the condition of the 
respiration. The moment the pulse becomes weak, the face pale, and 
the respiration embarrassed or stertorous, danger is imminent, and the 
anaesthetic must be discontinued. 

Sometimes unpleasant results follow want of attention to a certain 
preliminary preparation, which is of the first importance both as regards 
the safety of the patient and the result of operations. First, before 
the anaesthetic is administered the stomach should be empty, otherwise 
vomiting will almost surely follow the inhalation, which, in operations 
upon the eye, may cause the loss of that organ ; besides, the act of 
emesis being attended with more or less depression, may contribute 
measurably to the suspension of the heart's action, already enfeebled 
by the influence of the chloroform. Another advantage derived from 
attending to this point is that the diaphragm will have freer play in 
sustaining the respiration when not obstructed by a distended stomach. 

Secondly, all articles of clothing about the patient's person should 
be loosened, so that the walls of the thorax and abdomen be not com- 
pressed, to the detriment of a vigorous respiration. 

Thirdly, the inhalation should be gradual, so that the system may 
have time to accommodate itself to the altered conditions of functional 
activity ; the rapid administration of chloroform will produce a sort 
of shock, that may be fatal. 

Fourthly, the surgeon should assure himself that the chloroform is 
pure. 

The article obtained from methylated spirit is the best, but the ordi- 
nary article can generally be depended upon. The usual impurities 
are alcohol, the pyrogenous oils, and ether. If we place in a test-tube 
a little distilled water, and pour into it, guttatim, chloroform, if there 
is any alcohol present the mixture will become somewhat milky, but 
if that fluid is absent, the chloroform will fall to the bottom unchanged; 



ANAESTHESIA. 671 

a little of the albuminous fluid of an egg added to chloroform con- 
taining alcohol will be promptly coagulated. When poured upon the 
hand, any pyrogenous oil will leave upon it a greasy feel when the 
chloroform has evaporated. The addition of sulphuric acid will 
change the color of the oil to yellow or brown. If the suspected 
fluid be poured upon a sheet of white letter-paper, it leaves a greasy 
spot, produced by the absorption of the oil. Adulteration with ether 
is easily recognized by applying a flame to the mixture, which imme- 
diately inflames ; pure chloroform is combustible, but not inflammable. 

The quantity of chloroform required in each case will vary with 
the age, sex, and susceptibility of the patient, and the duration of the 
operation ; generally between half an ounce and an ounce will do, 
but in prolonged operations ten to sixteen ounces may be required. 
Young children require very little, and, as a general rule, females are 
more susceptible to its influence than males. Age is no bar to the 
administration of chloroform. 

If the agent has produced poisonous effects indicated by the Ghanges 
in the countenance, breathing, and pulse mentioned above, the inhala- 
tion must be instantly suspended, and recourse had to the following 
means of resuscitation : — 

1. Secure the largest possible supply of fresh air by throwing open 
the windows and doors. 

2. Dash cold water upon the face and chest of the patient. 

3. Establish artificial respiration by Marshall Hall's plan for inflat- 
ing the lungs, or, what I think better, that known under the name of 
Dr. Sylvester's method, which consists in raising the arm above and 
parallel with the head at regular intervals, so that the ribs may be 
alternately elevated and depressed fifteen or twenty times per minute. 
A third plan is also recommended by some — inflating the lungs by 
blowing into the patient's mouth ; as this introduces more or less car- 
bonic acid gas, it has been suggested to substitute for the mouth a pair 
of bellows. 

4. Run the point of the index finger over the tongue to its base, 
which may then be pressed forward, and the superior opening of the 
larynx gently touched so as to excite reflex action. 

5. Prof. Nelaton says that a plan which has always succeeded with 
him, and never to be neglected in these cases, consists in suspending 
the patient by the heels. 

6. Counter-irritation of the skin by percussing it with the hands, 
the application of mustard plasters, mustard baths, &c. 

Stimulating vapors, such as that of liquor ammonias, may be held 
beneath the nose ; enemas of oil of turpentine will also be of service. 
As soon as the patient can swallow, brandy or other stimulant should 
be given. 

It has been recommended to pass an electrical current along the 
spine. 

The same amount of care is not required in administering ether as 
chloroform, as it does not act near so energetically as the latter. 

The inhalation may be effected by pouring the ether into a coni- 



672 ANESTHESIA. 

cally-shaped sponge moistened with water and covered with oiled silk ; 
a folded napkin or towel will also answer very well. 

The first dose for an adult may be half an ounce ; the first whiffs of 
the vapor generally produce a slight cough and acts of deglutition, 
which soon, however, subside and are followed by a condition of ex- 
hilaration, sometimes violent excitement ; in a few seconds the patient 
becomes quiet, muscular relaxation and complete insensibility ensu- 
ing. 

When the patient begins to recover from the anaesthesia, he gene- 
rally evacuates the contents of the stomach, if it happens to contain 
anything. He feels confused, and there is some pain in the head, which 
last sometimes continues a day or two ; the odor of the vapor also 
hangs to the patient's breath for two or three days. 

The quantity of ether required in each case, under ordinary cir- 
cumstances, will be from four to six fluidounces, but in prolonged 
operations as much as fifteen or twenty ounces may be demanded. To 
produce complete anaesthesia the vapor must be breathed at least ten 
or twelve minutes, and sometimes it takes twenty or thirty, according 
to the age and susceptibility of the patient. 

The whole series of ethers possess properties analogous to those of 
sulphuric ether. 

Other agents besides the ethers and chloroform have been used as 
anaesthetics, among which are chlorocarbon, chloride of olefiant gas, 
bromide of ethyl, amylene, and keroselene. Chlorocarbon, or the 
bichloride of carbon, is a transparent, colorless fluid, having an ethereal 
odor and sweetish taste, not unlike chloroform, to which it still further 
assimilates in its quality and effects, but' is more dangerous than it, 
from the greater depressing influence exercised over the actions of the 
heart. The chlorocarbon has been used by inhalation, introduced into 
the stomach, and in the form of a vapor douche. In the latter mode 
particularly has it been found advantageous in hysteralgia, and pain- 
ful affections of the rectum. Prof. Simpson employed a simple appara- 
tus for the application of the douche, consisting of a common enema 
syringe with the nozzle introduced into the vagina, and the other ex- 
tremity of the apparatus placed an inch or more down into the interior 
of a four ounce phial containing a small quantity, as an ounce or so, 
of the fluid whose vapor it is wished to inject through the syringe. 

Chloride of olefiant gas and the bromide of ethyl have both been 
used by Mr. JSTunnely, of Leeds, and he believes them to possess im- 
portant advantages over chloroform. Patients can be put under their 
influence and kept insensible for any length of time, during the per- 
formance of the most painful operations; both these agents act speedily, 
pleasantly, and well. 

Amylene was experimented with by MM. Caillot and Giraldes, and 
made the subject of a report to the Academy of Medicine by M. Eobert. 
This agent is extremely fetid, produces the most violent symptoms in 
a few moments, while they as rapidly pass away. It has proved fatal 
in one case in the hands of Dr. Snow, of London, and, possessed of 
much safer and more convenient anaesthetics, the profession has very 
properly abandoned its use. 



ANESTHESIA. 673 

Keroselene, a liquid hydrocarbon with a tasteless and unirritating 
vapor, has been but lately brought forward, and requires further ex- 
periments to ascertain its value as an anaesthetic. 

Several other agents possess anaesthetic properties in some degree, 
but they are of no practical value, inasmuch as the majority of them 
have not been tried upon the human subject. The reader is referred 
for further information as regards these agents to The Transactions of 
the Provincial Med. and Surg. Association, London, vol. xvi. p. 177. 



43 



I X D E X 



Abdominal bandages, 142, 1S3 

hernia?. 255 
Actual cautery, 577 
Acupuncture, 591 
Acupressure, 652 
Adhesive plaster, 56 

mode of preparing, 56 
use of, 56 

application of, in the treatment of ulcers, 
147 
in the treatment of club-foot, 323 
in the treatment of orchitis, 150 
Agnew's apparatus for coxalgia. 342 
Aigrette of the silk-cotton tree as a dressing, 49 

of the silk-weed as a dressing, 50 
Amadou as a dressing, 50 
Ammonia as an antiseptic, 121 
Anaesthesia, 665 
Anchylosis, 319 
Anel's svrinee, 107 

probe, 619 
Aneurism, mechanical treatment of, 145 
Ankle, dislocation of, 561 
Ankle-joint, compound dislocation of, 567 
Angular curvature of the spine, 310 

cervical curvature, 293 
Antiseptics, 121 
ammonia, 121 
bisulphate of soda, 121 
bromine, 121 
carbolic acid, 121 
Anus, prolapsus of, 268 

Apparatus for angular cervical curvature, 293 
for angular curvature of the spine, 312 
for anterior curvature of the leg, 333 
for applying carbonic acid to the uterus, 

130 
for bowed legs, 332 
for bunion, 321 
for club-foot, 323 
for contraction of the knee, 333 
for coxalgia, 343 
of Dr. Davis for coxalgia, 339 
for deficiency of the abdominal walls, 227 
of the chin, 226 
of the cranial walls, 219 
of the eye, 223 
of the integuments, 220 
of the lips and cheeks, 223 
of the lower extremities, 237 
of the nose, 221 
of the palate, 223 
of the trunk, 227 
of the upper extremities. 228 
of the walls of the spinal canal, 228 



Apparatus — 

for deformitv of the chin and neck, 292 

of the elbow, 319 

of the finger, 317 

of the lips, 291 

of the wrist, 318 
of dressing, 33 

for extending a contracted stump. 242 
for immobility of the lower jaw, 290 
for lateral curvature of the spine, 304 
for loss of function of the cervical muscles, 
253 

of the dorsal muscles, 254 

of the ligaments of the hip-joint, 289 

of the ligaments of the knee-joint, 287 

of the muscles of the head and neck, 
252 

of the muscles of the thumb, 275 

of the muscles of the trunk, 233 

of parts of the body, 250 

of parts of the lower extremities, 280 

of parts of the upper extremities, 274 
for loss of svmmetry of the lower extremi- 
ties. *320 

of parts, 289 

of the pelvis, 314 

of the trunk, 297 

of the upper extremities. 315 
for paralysis of the biceps, 279 

of the common extensor of the fin- 
gers, 277 

of the extensors of the hand, 278 

of the interossei muscles of the fin- 
gers, 276 

of the lower extremities, 284 

of the peronei muscles, 2S2 

of the scapula muscles, 2S0 

of the tibialis anticus, 281 
for prolapsus ani, 268 
for posterior curvature of the spine, 310 

of the neck, 292 
for single lateral curvature, 309 
for talipes calcaneus, 331 
for torticollis, 295 
Application of atomized liquids to the interior 
cavities, 126 
of hot air to wounds, 124 
Application of trusses, 261 

of vapors and gases to the skin, 123 

of water by means of India-rubber sacks, 

95 
of water to the head, 96 

to the neck, 97 

to the spine, 97 

to the chest, 97 



676 



INDEX. 



Application of water — 

to the abdomen, 97 
to the limbs, 98 
Arm, application of tourniquet, 548 
Artery-forceps, 38 

Arteries, method of applying a ligature to 
bleeding, 651 
tortion of, 654 
Arteriotomy, 606 

Artificial arm of Ambrose Pare, 228 
of Bechard, 231 
of Charriere, 230 
common, 234 

of Gotz von Berlichingen, 229 
of Kolbe, 234 
of Gildea, 233 
of Van Petersen, 229 
with driving hook attached, 235 
eye, 222 
foot, 239 
leg of Bly, 245 

of Bechard, 250 
of Charriere, 250 
of Ferd. Martin, 250 
of Palmer, 249 
of Kolbe, 247 
of Mille, 250 
of Mathieu, 250 
of Beaufoy, 242 

for amputation below the knee, 241 
nose, 221 
palate, 224 

of Dr. Hullihen, 225 
Astragalus, dislocation of, 567 
Atomizer of Sales-Grirons, 128 
steam, 129 

Bandages — 

anterior figure of 8 of the head and axilla, 

178 
anterior figure of 8 of the shoulders, 180 
anterior double T of the head and chest, 

184 
anterior figure of 8 of the hand and wrist, 

198 
anterior figure of 8 of the knee, 210 
anterior sling bandage of the hand, 202 
bandage for the leg, 217 

for the foot, 217 
binocle, 162 

bis-oculo-occipital triangle, 172 
cap of the breast, 186 

of the head, 173 
carpo-olecranon cravat, 204 
carpo-cervical triangle, 205 
carpo-digito-dorsal triangle, 203 
cervico-thoracic cravat, 189 
cervico-dorso -sternal cravat, 189 
cervico-axillary cravat, 191 
cervico-brachial triangle, 205 
circular bandage of the leg, 207 

of a toe, 207 

of a finger, 194 

of the forearm, 194 

of the neck, 176 

of the chest and abdomen, 176 

of the forehead and eyes, 160 
circular cravat, 172 
compound metatarso-patellar cravat, 215 

bis-axillary cravat, 188 

dorso-bis-axillary cravat, 189 
coxo-pelvic triangle, 191 



Bandages — 

crossed bandage of the chest, ISO 

of one breast, 181 

of both breasts, 182 

of one groin, 182 

of both groins, 183 

of the head and neck, 165 

of the head, 165 
cravat for the neck, 187 
crucial bandage of the head, 169 
cruro-pelvic cravat, 190 
cravats for the lower extremities, 215 

for the upper extremities, 203 
deltoid bandage, 205 
double T bandage of the foot, 213 
double T bandage of the hand, 201 
double T of the pelvis, 184 
double T of the chest and abdomen, 183 
double T of the head, 168 
double T of the nose, 168 
double crossed bandage of the lower jaw, 

163 
dorsal triangle, 192 
extensor figure of 8 bandage of the hand 

and forearm, 199 
facial triangle, 173 
figure of 8 of the head and one axilla, 

177 
figure of 8 of the neck and axilla, 178 
figure of 8 of the thumb and wrist, 198 
figure of 8 of the elbow, 198 
figure of 8 of a toe, 209 
figure of 8 of the foot and leg, 210 
figure of 8 of both knees, 210 
four-tailed bandage of the chin, 170 
fronto-cervico-labial triangle, 173 
fronto-oculo-occipital triangle, 172 
fronto-occipital triangle, 172 
fronto-thoracic triangle, 188 
flexor figure of 8 of the hand and fore- 
arm, 199 
girdle, 193 

half cap of the head, 173 
imbricated squares and cravats for the 

lower extremity, 215 
invaginated bandage for transverse 
wounds, 212 

for longitudinal wounds, 211 

for the lips, 167 
interdigital triangle, 204 
intercrural cravat, 190 
knotted bandage of the head, 165 
laced bandage of the lower extremity, 
214 

of the body, 206 

of the arm, 203 
large quadrilateral scarf of the arm and 

chest, 200 
lateral thoracic bandage, 191 
mask, 171 

malleolar-phalangeal triangle, 216 
metatarso-malleolar cravat, 216 
monocle, 162 
oblique bandage of the neck and axilla, 

177 
oblique quadrilateral scarf of the arm and 

chest, 200 
occipito-frontal triangle, 172 
occipito-mental triangle, 172 
occipito-auricular triangle, 173 
ocular triangle, 174 
palmo-digito-brachial triangle, 204 



INDEX. 



677 



Bandage? — 

parieto-axillary triangle, 1S9 
perforated T bandage of the hand, 202 
posterior figure of 8 bandage of the knee, 

210 
posterior sling bandage of the elbow, 202 
posterior figure of 8 of the hand and 

wrist, 198 
quadrilateral bandage of the head, 167 
recurrent bandage of the hip, 211 

of the thigh, 211 

of the leg, 211 

of a stump of an arm. 199 

after disarticulation at the shoulder, 
199 

of the head, 166 
sacro-lumbar triangle, 190 
sacro-bicrural cravats, 190 
sacro-pubic triangle, 189 
scarf of the arm and neck, 201 

of the hand and forearm, *201 
sheath bandage of the nose, 171 

of the tongue, 171 

of the finsers, 194 

of a toe, 204 
sheath of the penis, 187 
shepherd's sling, 174 
simple bis-axillary cravat, 188 
simple dorso-bis-axillary cravat, 189 
single T bandage of the hand, 201 
single T bandage of the foot, 213 
simple crossed bandage for the lower jaw, 

163 
six-tailed bandage of the head, 170 
sling bandage of the hand, 202 

of the shoulder, 185 

of the breast, 1S5 

of the hip, 186 

of the instep, 213 

of the heel, 214 

of the knee, 214 
strait-jacket, 202 
spica of the shoulder, 179 
suspensory of the testicle, 187 
spiral bandage of the body, 177 
sternal triangle, 191 
spiral bandage of a toe, 201 

of the leg, 208 

of the thigh, 208 

of the lower extremities, 208 

of a finger, 195 

of all the fingers, 195 

of the hand and fingers, 196 

of the forearm, 196 

of the arm, 196 

of the whole arm, 197 
tarso-pelvic cravat. 216 
tarso-crural cravat, 216 
tarso-patellar cravat, 215 
T bandage of the mouth, 169 
T bandage of the groin, 184 
T bandage of the head, 168 
T bandage of the head and ears, 168 
thoracico-scapular triangle,' 189 
tibial triangle, 215 
triangular cap of stumps, 205 

of the shoulder, 205 

for stumps, 216 

for the heel, 216 

of the breast, 189 
triangular bandage of the head, 167 
triangle of the trochanter major, 217 



Bandages — 

uniting cord for longitudinal wounds, 217 
Bandage-scissors, 148 

Barwell's mode of attaching elastic cords in 
club-foot, 323 

splint for coxalgia, 341 
Baths, 98 

general, 98 

shower, 101 

vapor, 102 

warm air, 104 

dry, 104 

local, 104 

hip, 103 

foot, 106 
Bathing, 98 

Baynton's plan of healing ulcers, 187 
Bedsores, 97 
Belloc's sound, 621 

Bigg*s apparatus for caries of the cervical 
vertebrae, 294 

for torticollis, 296 

for lateral curvature, 306 

for contracted knee, 336 

for immobility of the lower jaw, 290 
Biere's couch for lateral curvature of the spine, 

202 
Bishop's apparatus for caries of the cervical 

vertebrae, 294 
Bistouries, 35 

straight, 35 

curved sharp-pointed, 36 

curved probe-pointed, 36 
: Bisulphate of soda as a disinfectant, 120 
Blisters, 575 
Bloodletting, 600 

Bonnet's apparatus for anchylosis of the elbow, 
319 

for torticollis, 295 

for contraction of the knee, 334 
Bougies, 625 

introduction of, into the oesophagus, 623 
into the bladder, 625 
Bourdonnet, 47 

mode of making, 47 

use of, 47 
Bowed or bandied legs, 331 
Bran-dressing, Barton's, 50 
Brodie's apparatus for lateral curvature, 307 
i Bromine as an antiseptic. 121 
Buchanan's compound circular catheter, 152 
Bullet of lint, 46 

mode of making, 46 

uses of, 46 
Bullet-forceps, 664 
Bunion, 321 

Bunsen : s battery for cauterization, 581 
Burns, 149 

treatment of, with adhesive strips, 149 

Canula for polypi, 156 

Carbon as a disinfectant, 120 

Carbonic acid gas in vesical disease, 130 
; Carbolic acid as a disinfectant, 121 
; Carpus, dislocations of, 539 
fractures of, 434 

Carte's compressors, 146 

Cartilages, semilunar, dislocation of, 560 

Cataplasms, 79 

retentive bandage for, 81 

Catch-forceps, 39 

Catheters, silver, 44 



678 



INDEX. 



Catheter, double, for injecting the bladder, 94 

male, 44 

female, 629 

syringe, 109 
Cat's tail as a dressing, 50 
Catheterism, 618 

of the nasal duet, 619 

of the Eustachian tube, 620 

of the posterior nares, 621 

of the oesophagus, 623 

of the larynx and trachea, 624 

of the large intestines, 625 

of the uterus, 625 

of the urethra, 625 

of the male urethra, 625 

of the female urethra, 629 
Cauterization, 577 

actual, 577 

galvanic, 579 

potential, 581 
Cauteries, 578 
Caustic-holder, 42 
Cerates, 62 

extemporaneous formulae for, 63 
Charriere's compressor, 146 
Charpie, 45 

mode of making, 45 

different sorts of, 45 
Chassaignac's ecraseur, 157 
Chloropercha, 59 
Chlorine as a disinfectant, 118 
Chloroform, use of, in operations, 668 
Chloride of zinc as a disinfectant, 120 
Cinnabar and the oxide of arsenic as disin- 
fectants, 121 
Clamp, Hoey's, 146 
Classification of bandages, 158 
Clavicle, dislocations of, 517 

fracture of, 397 
Closure of jaws, 290 
Clove-hitch, 507 
Club-foot, 322 
Coins in oesophagus, 635 

in trachea, 637 
Cold water-dressings, 87 
Cold, application of, in inflammation, 87 
Collodion, 58 

mode of preparing, 58 

how used, 58 
Collutories, 78 

extemporaneous forms of, 79 
Collyria, 74 

Common socket leg, 241 
Compound bandages, 158 
Compression bandages in fractures, 144 

for stumps, 144 

in aneurism, 145 
Compressor, 145 

Carte's, 146 

Charriere's, 146 

"Wales's, 147 
Compressive bandages, 144 
Compresses, 52 

folded, 52 

square, 52 

triangular, 52 

oblong, 52 

perforated, 52 

fenestrated, 52 

button-hole, 52 

single-split, 52 

double-split, 52 



Compresses — 

many split, 52 

sling, 52 

graduated, 54 
Constitutional disturbance in fracture, 350 
Contused wounds, 662 
Contraction of fingers, 315 

of thumb, 315 

of the knee-joint, 333 

of the hip, 336 

of the wrist, 317 

of the toes, 320 
Corrigan's button cautery, 572 
Coracoid process, fracture of, 394 
Corne and Demeau's disinfectant, 120 
Cotton, 48 

use of, 48 
Counter-irritation, 571 
Counter-irritants, different kinds of, 570 

actual cautery, 578 

blisters? 575 

caustic potash, 582 

dry cupping, 609 

issue, 586 

moxa, 585 

nitrate of silver, 582 



sinapisms, 572 

tartar emetic, 64 
Coxalgia, 337 
Cranium, fractures of, 573 
Crepitus, 348 
Cupping, 608 

dry, 608 
Curvatures of spine, 297 

angular, 310 

posterior, 309 

lateral, 297 

Davis's mode of treating coxalgia,339 
Deficiency of the arm, 288 

of the cranial walls, 219 

of the chin, 226 

of the ear, 223 

of the eye, 222 

of the integuments, 219 

of the leg, 237 

of the lips and cheeks, 223 

of the nose, 220 

of the palate, 223 

of the teeth, 226 

of the -thoracic, 227 

of the walls of the spinal canal, 228 
Deformities of the chin and neck, 291 

of the elbow, 318 

in fracture, 349 

of the finger, 315 

of the foot and ankle, 322 

of the lips from burns, 291 

of the nose, 289 

of the wrist, 317 
Deligation of arteries, 650 
Deprivation of function in fracture, 349 
Dewar's apparatus for supporting suture in 

hare-lip, 143 
Diastasis, 346 
Dilatation, 151 

of lachrymal canals, 151 

of stricture of oesophagus, 151 
neck of uterus, 151 
vagina, 151 
urethra, 151 



IXDEX 



679 



Dilators. 151 

oesophageal, 151 
uteriue, 151 
vaginal, 151 
urethral, 151 
Buchanan's, 152 
Sheppard's, 153 
wire, 152 
Wakely's, 153 
Director, 42 

use of, 42 
Disinfection, 117 
Disinfectants, 117 

Ledoyen's disinfecting fluid, 118 
carbon, 120 
cleanliness, 121 
chloride of soda, 118 
chloride of zinc, 120 
chlorine, 118 
bisulphite of soda, 120 
gunpowder, 120 
Sir W. Burnett's, 120 
ozone, 119 
Labarraque's, 118 
permanganate of potasaa, 120 
sulphurous acid gas, 120 
sulphite of soda, 120 
mixture of MM. Corne and Demeau, 120 
mixed gases of chlorine and hydrochloric 
acid, 119 
Dislocation, 500 
causes of, 502 

continuous elastic extension in, 510 
diagnosis of, 506 
frequency of, 501 
nomenclature of, 500 
of the astragalus upon the tibia, 561 

forwards, 561 

backwards, 562 

inwards, 563 

outwards, 564 

upwards. 565 

by rotation, 565 
of the carpus, 539 

backwards, 539 

forwards, 540 
of the clavicle, 517 

a. inner extremity, 518 

forwards, 518 
upwards, 519 
backwards. 520 

b. outer extremity, 520 

upwards, 520 
downwards, 522 

downwards under coracoid pro- 
cess, 523 

c. both extremities, 523 
of the femur, 548 

iliac, 548 
sciatic, 551 
thyroid, 552 
pubic, 554 
unusual, 555 
of the fibula, 560 

a. upper extremity, 560 

forwards, 560 
backwards, 560 

b. lower extremity, 561 

backwards, 561 
of the foot, 561 
of the head and trunk, 511 
of the humerus, 523 



Dislocation of the humerus — 
backwards, 531 
downwards, 523 
forwards, 530 
of the inferior maxilla, 511 
bilateral, 511 
unilateral, 511 
of the lower jaw, 511 
of the lower extremities, 547 
of the metacarpus, 541 
of the metatarsus, 568 
of the os magnum, 540 
of the patella, 556 
outwards, 556 
inwards, 557 
upwards, 557 
upon, its own axis, 557 
of the pelvic bones, 547 
ilium, 547 
sacrum, 547 
coccyx, 547 
of the phalanges of the fingers, 542 
of the phalanges of the toes, 569 
of the pisiform bone, 541 
of the radius and ulna, 532 
backwards, 532 
forwards, 534 
outwards, 535 
inwards. 535 

radius forwards and ulna backwards, 
536 
of the radius, 536 
backwards, 536 
forwards, 537 
outwards, 538 
of the ribs and costal cartilages, 516 
of the semilunar bone, 541 
of the semilunar cartilages, 560 
of the sternum, 516 
of the tarsal bones, 565 
astragalus, 565 
forwards, 566 
backwards, 566 
inwards, 566 
outwards, 566 
os calcis and scaphoid, 567 
backwards. 567 
inwards, 567 
outwards, 567 
cuboid and scaphoid, 568 

forwards and upwards, 568 
scaphoid, 568 

forwards, 568 
cuneiform bones, 568 
forwards, 568 
of the tibia, 557 
backwards, 558 
forwards, 558 
inwards, 559 
of the ulna, 538 

upper extremity, 538 

backwards, 538 
lower extremity, 539 
forwards, 539 
backwards, 539 
of the unciform bone, 541 
of the upper extremities, 517 
of the vertebrae, 514 
pathological anatomy of, 503 
prognosis of, 506 
symptoms of, 504 
treatment of, 566 



680 



INDEX, 



Dividing bandages, 143 
Double canula of Levret, 156 
Double-beaded roller, 136 

mode of application, 136 
Douche, 104 
Dressings, 88 

warm water, 87 

cold water, 89 

medicated water, 89 

of wounds, 658 
Drop-wrist, 278 
Dry fomentations, 89 

Ducbenne's apparatus for lateral curvature, 
307 

for paralysis of the common extensors of 
the fingers, 277 

for paralysis of the inter ossei muscles, 276 
Dupuytren's bandage, 53 

compressor, 649 

Ear, removal of foreign bodies from, 632 
Earle's triple-inclined plane for curvature of 

spine, 312 
Ecraseur, 157 

mode of action of, 157 

wire, 157 
Eighteen-tailed bandage, 53 
Elastic cords in the treatment of club-foot, 

323 
Electro-puncture, 592 
Epiphyses, separation of, 420 
Epistaxis, 621 
Ether, 671 

Eustachian catheter, 620 
Expelling bandages, 143 
Extraction of teeth, 614 
Eye, removal of foreign bodies from, 632 

vapors, 75 

powders, 75 

salves, 75 

Fibula, dislocations of, 560 
Finger, fractures of, 435 

use of as a director, 598 
First pieces of dressing, 44 
Flexed knee, 333 
Folded compresses, 54 
Fomentation, 89 
Foot-bath, 106 
Forceps, 38 

dressing, 38 
artery, 38 

with slide, 38 
with spring, 38 
for holding pins in making the twisted 

suture, 39 
Liston's, 39 
tooth-pointed, 40 
for extracting teeth, 614 
Foreign bodies, removal of from ear, 632 
from the nostrils, 635 
from the rectum, 641 
from the trachea, 637 
Formulae for collyria, 76 
for eye-powders, 79 
for eye-salves, 76 

for injections into the urethra, 109 
into the bladder, 110 
into the rectum, 114 
Fractures, 346 

adhesive straps in, 469 
apparatus for, 357 



Fractures — 

causes of, 347 

chalk and gum bandages in, 364 

classification of, 346 

complicated, 355 

compound, 354 

definition of, 346 

dextrine bandages in, 367 

diagnosis of, 350 

dressings of, 358 

frequency of, 347 

general treatment of, 355 

gutta percha in, 363 

immovable apparatus in, 365 

mode of repair, 350 

of the astragalus, 493 

of the calcaneum, 493 

of the carpus, 434 

of the clavicle, 397 

of the coccyx, 436 

of the costal cartilages, 343 

of the femur, 437 

of the upper extremity of the femur, 437 

intra-capsular, of the neck of the femur. 

437 
extra-capsular, of the neck of the femur, 

444 
of the trochanter major, 447 
of the shaft, 448 
of the condyles, 470 
of the fibula, 491 
of the head, 373 
of the humerus, 409 

anatomical neck of, 409 

tubercles of, 419 

vertical fracture of the head of, 410 

surgical neck of, 410 

shaft of, 413 

condyles of, 415 

external condyle of, 421 

internal condyle of, 422 

internal epicondyle of, 422 
of the hyoid bone, 386 
of the ilium, 436 

of the inferior maxillary bone, 378 
of the laryngeal cartilages, 387 
of the leg, 480 
of the lower jaw, 378 
of the lower extremities, 435 
of the malar bone, 378 
of the metacarpus, 434 
of the nasal bones, 374 
of the patella, 471 
of the pelvis, 435 
of the sacrum, 435 
of the coccyx, 436 
of the ilium, 436 
of the pubis and ischium, 436 
of the phalanges of the fingers, 435 
of the phalanges of the toes, 494 
of the radius and ulna, 423 
of the radius, 425 

upper extremity of, 425 

shaft of, 426 

lower extremity of, 426 
of the ribs, 511 
of the sacrum, 435 
of the scapula, 393 

acromion process of, 393 

coracoid process of, 394 

neck of. 394 

body of, 395 



INDEX. 



681 



Fractures — 

inferior angle of, 396 
of the skull, 373 
of the sternum, 390 
of the superior maxillary bone, 376 
of the tarsus, 493 
of the tibia and fibula, 480 
of the tibia, 490 
of the ulna, 431 

olecranon process of, 431 

coronoid process of, 433 

shaft of, 433 
of the upper extremities, 393 
of the upper jaw, 376 
of the vertebrae, 388 

lumbar, 388 

dorsal, 389 

cervical, 389 
of the zvgoma, 378 
plaster of" Paris splint in, 368 
pasteboard splints in, 359 
prognosis of, 350 
seat of, 347 
splints for, 357 
Scultetus' apparatus for, 372 
starched apparatus for, 366 
symptoms of, 348 
ununited, 352 

treatment of, 352 
varieties of, 346 
Fricke's plan of treating orchitis with adhe- 
sive strips, 150 
Fumigation, 123 
general, 123 
local, 123 

Galvanic issue, 588 
Gargles, 77 

formulae for, 78 
Gariel's compressor, 150 
Gases and vapors, uses of, 117 
Gateau, 46 

mode of preparing, 46 
General baths, 98 

rules for the preparation and application 
of bandages, 131 

bleeding, 600 
Genu-valgum, 284 
Glycerine, 70 

as a dressing, 71 

extemporaneous formulae for, 72 
Gross's arterial compressor, 649 
Gunshot wounds, 663 
Gunpowder as a disinfectant, 120 
Gutta-percha shoe in club foot, 325 

shield for cervical curvature, 294 

Half Maltese cross, 53 

mode of preparing, 53 
Hammer toe, 320 

Hartshorne, E., method of treating fracture of 
the patella, 477 
of the olecranon, 478 
of the clavicle, 408 
Hemorrhage, mode of arresting, 642 
Hernial bandages, 254 
Hernia, 255 

inguinal, 255 
crural, 255 
ischiatic, 255 
obturator, 255 
perineal, 255 



Hernia — 

pudendal, 255 

umbilical, 255 

vaginal, 255 

ventral, 255 
Hip-bath, 106 
Hip disease, 337 
Hoey's clamp for aneurism, 146 
Hypodermic injection, 146 

syringe, 115 

Ilium, fractures of, 436 
Immersion, 89 

mode of employing, 90 
Immobility of lower jaw, 290 
Improper bandaging in amputation, 145 
Importance of the early treatment in deformi- 
ties, 218 
Incised wounds, 655 
Incisions, 596 
India-rubber cap, 95 

sac for neck, 96 
spine, 97 
abdomen, 97 
limbs, 98 

pads for splints, 358 

in the treatment of umbilical hernia, 260 

suture, 660 
Indications answered by bandages, 139 
Influence of climate on the healing of wounds, 

124 
Inguinal truss, 256 
Inhalation, 126 

of camphor, 126 

of the narcotics, 126 

of nitrate of potassa, 126 

of iodoform, 127 

of oxygen, 127 

of chlorine, 127 

of atomized fluids, 128 
Inhalers, 126 
Injections, 106 

of the lachrymal duct, 107 

of the ear, 107 

of the urethra, 1 09 

of the bladder, 100 

of the vagina, 110 

of the uterus, 111 

of the rectum, 112 

of the cellular tissue, 115 

of the abnormal canals, 116 
Instruments for dressing, 33 
Interrupted suture, 659 
Introduction of catheter, 626 

of pessaries, 273 
Irons for the actual cautery, 578 
Irrigations, 90 

mode of applying, 92 

cold, 92 

warm, 92 

of nasal fossae, 93 

of the bladder, 94 

of vagina and uterus, 94 
Isinglass plaster, 58 

mode of preparing, 58 

use of, 58 
Issue, 586 

Jarvis's apparatus for reducing dislocations, 

510 
Joints, false, 352 
Jb'rg's apparatus for torticollis, 295 



682 



INDEX. 



Keroselene, 673 
Knock knee, 284 
Knot-tighteners, 156 

Graefe's, 156 

Roderic's, 156 
Knots, 55 

clove hitch, 55 

double noose, 56 

double, 55 

double bow, 55 

double knotted and looped, 56 

crossed slip, 56 

loop, 55 

packer's, 55 

reef, 55 

single noose, 55 
bow, 55 

single, 55 

surgeon's, 56 

sailor's, 56 

single slip, 56 

weaver's, 56 
Kolbe's apparatus for club-foot, 326 

for contraction of the knee, 333 
for lateral curvature, 308 
for torticollis, 296 

Labarraqtje's disinfectant solution, 118 
Lancet, 40 

Syme's, 40 
spring, 603 
abscess, 41 
thumb, 40 
gum, 41 
Lateral curvature of the spine, 297 
Ledoyen's disinfecting fluid, 118 
Leeches, 611 
Leeching, 610 
Leeches, hemorrhage from wounds made by, 

612 
Leg, application of tourniquet to, 615 
Ligatures, 154 

mode of action of, 154 
mode of applying, 154 
Fergusson's mode of applying, 155 
Erichsen's mode of applying, 155 
Linear compression, 154 
Liniments, 69 

extemporaneous formulae for, 70 
Lint, 44 

patent, 45 
scraped, 48 
Liquor sodae chlorinat. as a disinfectant, 118 
Liston's apparatus for club-foot, 329 
Little's apparatus for club-fot, 327 
Local baths, 104 

bleeding, 608 
Lonsdale's apparatus for lateral curvature, 

306 
Loss of function of the biceps of the arm, 279 
of the cervical muscles, 252 
of the extensor communis digitorum, 

277 
of the extensors of the hand, 278 
of the interossei muscles of the hand, 

276 
of the muscles of the fingers, 274 
of the muscles of the abdomen, 254 
of the tibialis anticus, 281 
of the sphincter ani, 267 
of the extensor muscles of the legs, 
282 



Loss of function — 

of the scapular muscles, 279 

of the peronei muscles, 281 

of the ligaments of the hips, 289 

of the ligaments of the knee-joint, 

284 
of the uterine ligaments, 268 
of parts of the head and neck, 219 
of symmetry of the pelvis, 314 
Lotions, 72 

extemporaneous formulae for, 62 

Maisonabe's couch for lateral curvature of 

the spine, 303 
Main au griffe, 276 
Maissonneuve's plan of cauterization, 584 

ecraseur, 157 
Maltese cross, 54 

mode of preparing, 54 
Manner of opening abscesses, 593 
Maw's metallic syringe, 112 
Mayor's system of bandaging, 137 
Meche, 47 

common, 47 

linen, 47 

cotton, 47 

use of, 47 
Mechanism of the joints of artificial legs, 243 
Mechanical condition of the natural leg, 238 
Mechanical bandages, 159 

leech, 613 

apparatus and bandages, 218 
Medicated water-dressing, 89 

pessaries, 111 

formulae for, 111] 
Mercie's mode of making splints, 259 
Metallic plates as a dressing, 50 

application of, 50 
Metacarpal bones, dislocation of, 541 

fracture of, 434 
Mode of attaching artificial legs, 241 

of holding scalpel, 597 

of making pasteboard splints, 259 

plaster of Paris splints, 368 

of repair in fracture, 350 

of treating loss of function of muscles, 
252 

of arranging spiral springs in the ankle- 
joint of artificial legs, 244 

of making trusses, 255 

of supporting the breast with adhesive 
strips, ,141 

of fixing terminal end of rollers, 136 
Modelling process, 661 
Morbus coxarius, 337 

Morgan's sound for dilating nasal duct, 620 
Most convenient length of arm for artificial 

limb, 237 
Moss, 50 

use of, as a dressing, 50 
Moxa, 585 
Moxibustion, 586 

Nasal duct, obstruction of, 619 
Naevus, 154 

Erichsen's mode of ligating, 155 

Fergusson's mode of ligating, 155 
Needles, 43 

surgical, 43 

exploring, 43 

artery, 43 

for twisted suture, 659 



INDEX. 



683 



Non-union of fracture, 352 
Nostrils, plugging of, 621 

removal of foreign bodies from, 635 

Oakum, 49 

use of in gunshot wounds, 49 

physical characters of, 49 

mode of applying, 49 
Obturator hernia, 261 

for the palate, 224 
Ointments, 64 

extemporaneous formulas for, 66 
Olecranon, fracture of, 431 
Orchitis, chronic, treatment of with adhesive 

straps, 150 
Orthopraxy, 218 
Ozone as a disinfectant 119 

Pads for splints, 358 
Pain in fractures, 350 
Palate, 223 

artificial, 224 

fissure of. 223 
Paralysis of the tibialis anticus, 281 
Patella, dislocation of, 556 

fracture of, 471 
Pasteboard splints, 359 
Pea issue, 587 
Pellet of lint, 47 

mode of preparing, 47 
use of. 47 
Pelvis, dislocation of, 547 

fracture of, 435 
Permanganate of potassa as a disinfectant, 120 
Pessaries, 269 

common, 269 

Zwanck's, 269 

Cloquet's, 269 

India-rubber, 270 

Hodge's, 271 

sponge, 271 

Bauhin's, 272 

Prunel's, 272 * 

Mayor's, 272 

Gariel's, 272 

supported by an external bandage, 272 

introduction of, 273 
Phalanges, dislocation of, 542 

fracture of, 535 
Phlebotomy, 600 
Physick's artery forceps, 652 
Plaster, application of adhesive, to wounds, 
657 
to testicle, 150 
to ulcers, 147 

isinglass, 58 
Plasters, 67 

extemporaneous formulae for, 67 
Pliers for cutting pins, 660 
Plumasseau, 46 

mode of preparing, 46 

use of, 46 
Plugging posterior nares, 621 
Pocket-case, 34 

Points of bearing of artificial leg, 243 
Portable shower bath, 102 
Porte-caustic, 42 
Porte-moxa, 585 
Porte-meche, 42 
Posterior curvature of the neck, 292 

of the spine, 309 
Post's mode of treating club-foot, 325 



Potassa caustic, 582 
Poultices, 79 

mode of preparing, 79 
different forms of, 84 
Preternatural mobility in fractures, 348 
Primitive forms of Mayor's bandage, 138 
Prince's mode of using elastic cords in club- 
foot, 324 
Probang, 41 
Probes, 41 

simple, 41 
eyed, 41 
grooved, 41 
gunshot, 41 
Probe-pointed bistoury, 36 
Projection of the chin, 291 
Prolapsus ani, 267 

mode of reduction, 297 
apparatus for, 268 
partial, 267 
complete, 267 
uteri, 269 
Protective bandages, 140 
Pseudarthrosis, 352 
Pulleys for reducing dislocations, 508 
Punctured wounds, 662 
Puncturing, 592 
Purification of the air of hospitals, 117 

Quilled suture, 661 

Kadius, dislocation of, 536 

fracture of, 425 
Raw silk, 49 

use as a dressing, 49 
Razor, 37 

mode of using, 37 
Rectum, stricture of, mechanical treatment of, 

625 
Recamier's method of making compression, 

150 
Recumbent couch for lateral curvature, 301 
Reef-knot, 55 
Removal of foreign bodies, 630 

from the skin, 630 

from the eye, 632 

from the ear, 632 

from the nose, 635 

from the pharynx and oesophagus, 635 

from the larynx and trachea, 637 

from the urethra and bladder, 639 

from the vagina, 641 

from the rectum, 641 
Retention of urine, 626 
Retaining bandages, 141 
Retractors, 52 
Ribs, dislocations of, 516 

fractures of, 321 
Rigal's system of bandaging, 139 
Roller bandages, 132 

of linen, 132 

of caoutchouc, 132 

of cambric, 132 

of calico, 132 

of cotton, 133 

mode of fastening pieces together . 
133 

kind used in Germany, 133 

mode of making with the hands, 134 

mode of making with the machine. 
135 

mode of applying, 135 



684: 



INDEX. 



Roll of lint, 46 

mode of preparing, 46 

use of, 46 
Rubefaction, 570 
Rubefacients, 571 
Rupture of the tendo-Achillis, 495 

Sailor's or reef-knot, 55 
Salmon and Ody's truss, 256 
Sawdust as a dressing of wounds, 50 

mode of using, 50 
Scalpels, 50 

single bladed, 34 

double bladed, 34 

different forms, 35 

metbod of holding, 35 
Scapula, fracture of body of eoracoid process, 

394 
Scarpa's shoe for club-foot, 326 
Scarificator, 609 
Scarification, 592 
Scissors, surgical, 36 

straight, 36 

curved on the flat, 37 

curved on the edge, 37 

mode of using, 37 
Scraped lint, 48 

mode of preparing, 48 
Scrivener's spasm, 53 
Scultetus' bandage, 53 

application of, 53 

lever for immobility of lower jaw, 290 
Semilunar cartilages, displacements of, 661 
Serrefine, 661 
Seton, 589 

Second pieces of dressing, 131 
Seutin's mode of treating fracture, 360 

scissors, 293 
Sheppard's dilator for stricture of the urethra, 

153 
Shower-bath, 101 

Shoulder-joint, dislocations of, 523 
Simple bandages, 131 
Sinapisms, 571 
Single headed roller, 134 
Sir William Burnett's disinfectant fluid, 120 
Sling compress, 53 
Smee's moulding tablet, 364 
Snell's artificial nose, 221 
Solution of shellac as an agglutinative, 59 
Spatulas, 42 

French, 42 
Special systems of bandaging, 137 
Mayor's, 137 
Rigal's, 139 
Spina bifida, 228 
Spine, curvatures of, 297 

fractures of, 388 

dislocation of, 514 
Spinal debility, 253 
Splints, 357 

of plaster of Paris, 368 

Amesbury's, 455 

Dupuytren's, 493 

Bond's, 428 

Boyer's, 461 

Desault's, 460 

Fergusson's, 487 

Gibson's, Hagedorn, 440 

Hartshorne's, 462 

Hays', 429 

Hutchinson's, 484 



Splints — 

Hamilton's, 475 

Liston's, 442 

Lansdale's, 476 

Lonsdale's, 476 

Mayo's, 420 

Nelaton's, 427 

Physick's, 461 

Smith's, N. R.,467 

Wales', 385 
Sponge, 47 

as a dressing to wounds, 50 
in compound fracture, 50 

probang, 624 

tent, 47 

mode of preparing, 47 
use of, 47 
Spongio-piline, 84 

Spring compressor for ganglionic tumors, 150 
Spring lancet, 603 
Starch bandages, 366 

treatment of fractures with, 366 
Sternum, fracture of, 390 
Stitches, application of, 658 
Stomach pump, 623 

Stricture of the urethra, treatment of, 151 
Stromeyer's apparatus for anchylosis of the 
elbow, 319 

foot-board for club-foot, 329 
Styles for dilating nasal duct, 620 
Styptic colloid, 59 

mode of preparing, 59 
how used, 60 
combinations of, 60 
Styptics, 644 

Subcutaneous ligature, 156 
Sulphite of soda as a disinfectant, 120 
Sulphurous acid as a disinfectant, 120 
Supporting frame for paralysis of the lower 

extremities, 282 
Surgical tray, 61 

wallet, 61 
Suspensory bandages, 142 
Suspension in the treatment of fractures of 

the lower extremities, 142 
Suture, 658 

interrupted, 658 

continuous, 659 

twisted, 659 

quilled, 660 

silk, 44 

iron, 44 - 

lead, 44 

silver, 594 
Syme's absces lancet, 41 

Talipes, 530 
valgus, 322 
varus, 330 
calcaneus, 328 
equinus, 328 

Stromeyer's foot-board for, 329 
Little's apparatus for, 327 
Liston's apparatus for, 329 
treatment of, with elastic cords, 323 
with adhesive strips, 323 
Tamplin's apparatus for contracted knee, 335 
for angular curvature, 313 
for lateral curvature, 395 
for posterior curvature, 310 
Tampon, 47 

mode of preparing, 47 



INDEX. 



Tampon — 

use of, 47 
Tartar emetic ointment, 64 
Taxis, 263 

Wise's mode of, 265 

Despre's mode of, 265 

of inguinal hernia, 264 

of crural hernia, 264 

of umbilical hernia, 267 

Seutin's mode of, 265 
Tavernier's apparatus for lateral curvature, 

304 
Teeth, artificial, 226 
Tenaculum, 40 

mode of using, 40 
Tenaculum-needle, 652 
Tent, 47 

mode of preparing, 47 
Tenotome, 600 
The wooden-pin leg, 242 
The "moulding tablet'' in fractures, 364 
Thompson's bathing apparatus, 101 
Thread for ligatures, 44 

for sutures, 44 
Thumb, dislocations of, 542 
Tibia, dislocation of, 557 

fracture of, 490 

posterior displacement of, 335 
Tibialis anticus, paralysis of, 281 

and peronei muscles, paralysis of, 
281 
Todd's truss, 257 
Toe contracted, 320 

fracture of, 494 

deformity of, 320 

hammer, 320 
Topical remedies, 62 

mode of action of, 62 
Torticollis, 294 
Tortion of arteries, 655 
Tourniquet, description of, 645 

application of, to superior extremity, 648 
to inferior extremity, 648 

for aneurism, Carte's, 146 
Tow, 49 

use of, 49 
Toynbee's syringe, 108 
Trachea, 637 

removal of foreign bodies from, 637 
Treatment of ununited fracture, 352 
Trocar, 594 

Trunk, deformities of, 297 
Truss, Arnott's, 257 

Bigg's, 257 

Bourgeand's, 259 

Coles', 257 

crural, 260 

Dupre's, 259 

femoral, 260 

Hood's, 258 

inguinal, 256 

moc-main, 259 

Salmon and Ody's, 256 

Todd's, 257 

umbilical, 261 

for prolapse of the rectum, 268 

Wickharn's, 257 

Stagner's, 258 
Tumors, 154 

removal of, by ligature, 154 



Twisted suture, 660 
Typha as a dressing, 58 

Ulcers, 147 

treatment of, by compression, 147 
Ulnar fracture, 431 
Ulna and radius, dislocation of, 532 

fracture of, 423 
Union by first intention, 661 
Uniting bandages, 42 
Ununited fracture, 352 
Urethral stricture, treatment of, 152 
Use of water generally, 98 

in surgical diseases, 85 
Uterine supporters, 272 

West on, 272 

Vaccination, 594 

Valerius' "corset-lit," 302 

Van Petersen's artificial arm, 229 

Vapor-bath, 103 

Vapors and gases, uses of, 117 

Varus, 322 

Velpeau's apparatus for writer's cramp, 275 

bandage for supporting pendulous abdo- 
men, 142 

treatment of burns with adhesive strips, 
149 
Venesection, 600 

in external jugular, 605 
Ventilation. 122 

of ships, 122 

by steam-engine, 123 
Ventilator of Brindejonc, 122 
Verral's couch for curvature of spine, 312 
Vesicants, 573 
Vesication, 573 
Vessel for hip-bath, 106 

Wakely's dilator for stricture of the urethra, 

153 
Wales' compressor for aneurism, 147 

sawdust dressing, 51 

splint for fracture of the lower jaw, 384 
Warm water-dressing, 88 

air-bath, 104 
Water as a surgical dressing, 86 
Water-cushions, 98 
Water-glass, 59 

mode of preparing, 59 
Winder, ivory, for ligature thread, 44 
Wire urethral dilator, 152 

splint for coxalgia, 344 
Wolf's jaw, 223 
Womb, prolapse of, 268 
Wool, 49 

physical characters of, 49 

use of, as a dressing, 49 
Wounds, 655 

contused, 662 

gunshot, 663 ' 

incised, 655 

punctured, 662 

mode of healing, 661 

method of dressing, 658 
Wrist-joint, dislocation of, 539 

contraction of, 317 
Wrist drop, 278 

Writer's or scrivener's cramp, 294 
Wry-neck, 294 



VALUABLE WORKS ON SURGERY. 



GROSS'S SURGERY. 
A SYSTEM OF SURGERY: Pathological. Diagnostic, Therapeutic, and 

Operative. By Samuel D. Gross, M. D., Professor of Surgery in the Jefferson Medical Col- 
lege of Philadelphia. Illustrated hy upwards of Thirteen Hundred Engravings. Fourth 
edition, carefully revised, and improved. In two large and beautifully printed royal octavo 
volumes of 2200 pages, strongly bound in leather, with raised bands. $15 00. 

DRUITT'S SURGERY. 
THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. By 

Egbert Druitt, M. R. C. S., &e. A new and revised American, from the eighth enlarged 
and improved London edition. Illustrated with four hundred and thirty-two wood engrav- 
ings. In one very handsome octavo volume, of nearly 700 large and closely printed pages. 
Extra cloth, S4 0*0 ; leather, 85 00. 

ERICHSEN'S SURGERY. 
THE SCIENCE AND ART OF Sr^GERY: being a Treatise on Surgical 

Injuries, Diseases, and Operations. By John Erichsex, "Professor of Surgery in University 
College, London. New and improved American, from the Second enlarged and carefully 
revised London edition, with over 400 wood engravings. In one large and handsome octavo 
volume of 1000 closely printed pages ; extra cloth, $6 ; leather, raised bands, $7. 

PIRRIE'S SURGERY. 
THE PRINCIPLES AND PRACTICE OF SURGERY. By William 

Pirrie. F. R. S. E., Professor of Surgery in the University of Aberdeen. Edited by John 
Neill, M. D. In one very handsome octavo volume of 780 pages, with 316 illustrations, 
extra cloth. $3 75. 

MILLER'S PRINCIPLES OF SURGERY. 

PRINCIPLES OF SURGERY. By James Miller, late Professor of Sur- 
gery in the University of Edinburgh, &c. Fourth American, from the third and revised 
Edinburgh edition. In one large and very beautiful volume of 700 pages, with two hun- 
dred and forty illustrations on wood, extra cloth. $3 75. 

MILLER'S PRACTICE OF SURGERY. 
THE PRACTICE OF SURGERY. By James Miller, late Professor of 

Surgery in the Univ. of Edinburgh. Fourth American from the last Edinburgh edition. 
Revised by the American editor. Illustrated by three hundred and sixty-four engravings 
on wood. In one large octavo volume of nearly 700 pages, extra cloth, 83 75. 

MALGAIGNE'S OPERATIVE SURGERY. Witb numerous illustrations 

on wood. In one handsome octavo volume, extra cloth, of nearly 600 pages. $2 50. 

SKEY'S OPERATIVE SURGERY. In one very handsome octavo volume, 

extra cloth, of over 650 pages, with about 100 wood-cuts. $3 25. 

SARGENT'S MINOR SURGERY. 
ON BANDAGING AND OTHER OPERATIONS OF MINOR SURGERY. 

Ey F. W. Sargent, M. D. New edition, with an additional chapter on Military Surgery. 
One handsome royal 12mo. volume, of nearly 400 pages, with 184 wood-cuts. Extra cloth, 
$1 75. 

GIBSON'S INSTITUTES AND PRACTICE OF SURGERY. Eighth 

edition, improved and altered. With thirty-four plates. In two handsome octavo volumes, 
about 1000 pages, leather, raised bands. $6 50. 

COOPER'S LECTURES ON THE PRINCIPLES AND PRACTICE OF 

SURGERY. In one very large octavo volume, extra cloth, of 750 pages. $2. 

BRODIE'S CLINICAL LECTURES ON SURGERY. 1 vol. 8vo., 350 

pages ; cloth, $1 25. 

barwell on the joints. 
A TREATISE ON DISEASES OF THE JOINTS. By Richard Bar- 

well, F. R. C. S., Assistant Surgeon Charing Cross Hospital, &c. Illustrated with engrav- 
ings on wood. In one very handsome octavo volume of about 500 pages ; extra cloth, $3. 



HENRY C. LEA, Philadelphia. 



VALUABLE WORKS ON SURGERY. 



HAMILTON ON FRACTURES AND DISLOCATIONS. 
A PRACTICAL TREATISE ON FRACTURES AND DISLOCATIONS. 

By Frank H. Hamilton, M. D., Professor of Fractures and Dislocations, &c, in Bellevue 
Hosp. Medical College, New York. Third edition, thoroughly revised. In one large and 
handsome octavo volume of 777 pages, with 294 illustrations, extra cloth, $5 75. 

GROSS ON THE URINARY ORGANS. 

A PRACTICAL TREATISE ON THE DISEASES, INJURIES, AND 

MALFORMATIONS OF THE URINARY BLADDER, THE PROSTATE GLAND, AND 
THE URETHRA. By S. D Gross, M. D., Professor of Surgery in the Jefferson Med. 
College, Phila. Second edition, revised and much enlarged, with one hundred and eighty- 
four illustrations. In one large and very handsome octavo volume, of over nine hundred 
pages, extra cloth. $4. 

MORLAND ON THE URINARY ORGANS. 

DISEASES OF THE URINARY ORGANS ; a Compendium of their Diag- 
nosis, Pathology, and Treatment. By W. W. Morland, M. D. With illustrations. In 
one large and handsome octavo volume of about 600 pages, extra cloth. $3 50. 

CURLING ON THE TESTIS. 

A PRACTICAL TREATISE ON DISEASES OF THE TESTIS, SPER- 
MATIC CORD AND SCROTUM. By T. B. Curling, F. R. S., Surgeon to the London 
Hospital, President of the Hunterian Society, &c. Second American, from the second and 
enlarged English edition. In one handsome octavo volume, extra cloth, with numerous 
illustrations, pp. 420. $2. 

ASHTON ON THE RECTUM. 

ON THE DISEASES, INJURIES, AND MALFORMATIONS OF THE 

RECTUM AND ANUS ; with remarks on Habitual Constipation. By T. J. Ashtqn. Se- 
cond American, from the fourth and enlarged London edition. With handsome illustrations. 
In one very beautifully printed octavo volume of about 300 pages. $3 25. 

GROSS ON FOREIGN BODIES. 

A PRACTICAL TREATISE ON FOREIGN BODIES IN THE AIR- 

PASSAGES. By S. D. Gross, M. D., Professor of Surg, in Jeff. Med. Coll., Phila. In 
one handsome octavo volume, extra cloth, with illustrations, pp. 468. $2 75. 

TOYNBEE ON THE EAR. 

THE DISEASES OF THE EAR: their Nature, Diagnosis, and Treatment 
By Joseph Toynbee, P. K. S., Aural Surgeon to and Lecturer on Surgery at St. Mary' 
Hospital. With one hundred engravings on wood. Second American edition. In one very 
handsomely printed octavo volume of 440 pages ; extra cloth, $4. 

LAURENCE AND MOON'S OPHTHALMIC SURGERY. 

A HANDY-BOOK OF OPHTHALMIC SURGERY, for the use of Practi- 

tioners. By John Laurence, F. R. C. S., Editor of the Ophthalmic Review, &c, and Rob- 
ert C. Moon, House Surgeon to the Southwark Ophthalmic Hospital, &c. With numerous 
illustrations. In one very handsome octavo volume, extra cloth. $2 50. 

LAWSON ON OPHTHALMIC INJURIES. 

INJURIES OF THE EYE, ORBIT, AND EYELIDS : their Immediate 

and Remote Effects. By George Lawson, F. R. C. S., Engl., Assistant Surgeon to the 
Royal London Ophthalmic Hospital, Moorfields, &c. With about one hundred illustrations. 
In one very handsome octavo volume, extra cloth, $3 50. {Just Ready.) 

JONES ON THE EYE. 

THE PRINCIPLES AND PRACTICE OF OPHTHALMIC MEDICINE 

AND SURGERY. By T. Wharton Jones, F. R. S., Professo* of Ophthalmic Med. and 
Surg, in University College, London. With one hundred and seventeen illustrations. Third 
and revised American, with Additions from the second London edition. In one handsome 
octavo volume of 455 pages, extra cloth. $3 25. 

MACKENZIE ON THE EYE. 
A PRACTICAL TREATISE ON DISEASES AND INJURIES OF THE 

EYE. By W. Mackenzie, M. D. From the fourth revised and enlarged London edition. 
With Notes and Additions by Addinell Hewson, M. D. In one very large and handsome 
octavo volume of 1027 pages, extra cloth, with plates and numerous wood cuts. $6 50. 



HENKY C. LEA, Philadelphia. 



Mm\h 



•' z ^: 



Wto 



*mm\ 



#s, 






;W^an 



„ '■ 






w 



m*m^.- M : : :mKM 



'*' ' v "> 



ffiif^ 



WF/imam 



WWr 



WW? 








^w 



/^sTWA 



r -. „ . r\ ~ 



Ai ^.V 



Ml 



TO^ 



^V^XaA' 









■rife s U*W ■>:::; 



A*A.A ft» 



itfSHHR 



$04 



.«*:. 






^^'•44l*.^M' 






,<y p 



,— 






Hfcu&^V 







* h **\-k&*x 






LIBRARY OF CONGRESS 



021 070 664 1 






■ 



m m 



- 



'4LJT? 









***..-' 



m^c«e^ 






w 



mm 




frcS 


B&-" "■ >■■ 






< 4|^H 















**s 






«BB* 



«sr« 



■ 
■ 

flffli ■ 



